Remarks by
A. Kathryn Power, M.Ed.
Director
Center for Mental Health Services
Substance Abuse and Mental Health Services Administration
U.S. Department of Health and Human Services
Collaborative Family Healthcare Association
Eighth Annual Conference
“Best Practices in Collaborative Healthcare”
Keynote Address
Transformation In Collaborative Healthcare
November 4, 2006
Newport, Rhode Island
PowerPoint version
Attached is the text prepared for delivery; however, some material may have been added or omitted at the time of delivery.
[SLIDE 1: Title Slide]
Thank you, Michael (Dr. Michael Fine, Co-Chair of the Allied Advocacy Coalition for Integrated Primary Care) for you introduction. I consider it an honor and a privilege to be introduced by a man who is recognized for his excellence in family medicine and his leadership by example in integrating behavioral and primary care.
It’s good to be here, with all of you today. Washington, D.C., is where my office is located, but Rhode Island is my home.
This is an exciting conference with parallel tracks designed to focus on specialized areas of interest…the areas where each of you generate your professional energy. These tracks provide wonderful opportunities for each of us to expand our horizons and re-energize ourselves for the work ahead. But, what excites me most about a forum like this one is the opportunity it provides to transform our individual energies into a collaborative energy. To realize the goal of a transformed, collaborative system of care focused on the real needs of consumers, we must transform our energy into synergy.
This morning I am going to talk about transformation and update you on the work that SAMSHA and our Federal Partners are doing to advance transformation across the behavioral health field. I am going to talk about the urgent need for the integration of behavioral health care with primary health care as a key component of the synergistic system we envision. And, finally, I’m going to talk about the complex networks that can work together at the Federal, state, local and personal level to create the momentum needed to make sure all Americans have access to and receive the full spectrum of care they need.
Today we understand the concept that "Everything is connected to everything else," as John Donne wrote so long ago in the words "No Man Is an Island." The mind and body are no longer viewed as separately functioning systems.
This is a huge shift in our thinking of how to provide services, but many people are taking the leap along with us. Let me share a story about Albert-László Barabási (Lazy-low Bar-ah-BAH-see), a scientist and Professor of Physics at the Universit of Notre Dame, where he directs research on complex networks.
In his book, LINKED1, he uses the example of the decoding of the human genome. Dr. Barabási says:
"If you were to open ‘the book of life’ you will see a ‘text’ of about 3 billion letters, filling 10,000 copies of the New York Times Sunday edition."
1Barabási, Albert-László. LINKED: The New Science of Networks. Perseus Publishing: Cambridge, MA. 2002
[SLIDE 2: ]
Each line would read something like this…
These letters—abbreviations of the molecules making up the DNA—we have been repeatedly told, reveal everything from our personality to our future medical history. Can you decode it? Neither can biologists or doctors.
At least, not yet.
Dr. Barabási’s comments are intriguing… “The sequencing of the human genome is a triumph,” he said, “the result of modern molecular biology’s ability to reduce complex living systems to their smallest parts. It is undoubtedly a catalyst of a new era in both medicine and biology. But the genome project has brought along a new realization: The behavior of living systems can seldom be reduced to their molecular components.
"Our inability to find a single gene responsible for manic depression is the best illustration. A list of suspected genes is not sufficient. To cure most illnesses, we need to understand living systems in their integrity. The decoding of the human genome offered us an inventory of the cell’s parts."
He concludes… "It’s like having thousands of car parts in your backyard. If you ever want to see that car running again, you must find the blueprint, a map telling you how to assemble it."
His description can be applied to our challenge of transforming our health care services system into one that can provide the integrated behavioral and primary care that the people of our Nation deserve. Thousands of parts make up the multiple dimensions of care...it is a vast, complex network of networks. We need to create a blueprint that will define and organize the roles that we all have to play in creating this new and different system of care.
Our mission, this morning, is to apply a systems approach to begin to create the blueprint we will need to build and strengthen our collaborative networks at the national, state, local and individual levels.
[SLIDE 3: ATP]
I’d like to take a moment, here, to give a little background on the monumental change that is taking place across behavioral health that is fueling transformation. In the past there was a tendency to look at each part of our health care system…isolate what was broken…and try to fix it. That works on machines…but not on living human systems. We know now that consumers and families are at the very center of our network of living systems and we have to transform the rest of our support around them. This is precisely what SAMHSA and our partners across the Federal government are doing.
Several years ago, the President’s New Freedom Commission on Mental Health released its final report—called Achieving the Promise: Transforming Mental Health Care in America. This report declared that millions of Americans with mental illnesses were being denied this promise. Stigma and discrimination, fragmented and inadequate services, poor opportunities for consumer involvement and self-determination—these were the barriers to their hope in recovery and a life in the community.
The report concluded that the only way to keep our promise to all Americans was to transform our mental health system.
Reform wasn’t good enough. As Maya Angelou once said, "The need for change bulldozed a road down the center of my mind."
The need for change highlights a critical need to move toward a transformed mental health system, where we can strengthen the accessibility and delivery of mental health services in every possible care setting and health care providers from every setting work collaboratively to provide more coordinated and effective care.
[SLIDE 4: Federal Partner Workgroup]
Successful transformation will require collaboration and cooperation across and among all levels of government, across agencies, between the private and public sectors, among service providers and consumers and their families. This kind of interdisciplinary collaboration is the lifeblood of the transformation process. SAMHSA is leading the charge for collaboration at the Federal level.
What does this Federal collaboration mean in real terms? It means that these agencies—all of which serve individuals with mental disorders and their families—are working together to leverage their resources to provide the services and support consumers and their families need to build resilience and facilitate recovery.
[SLIDE 5: Action Agenda]
Transforming Mental Health Care in America: The Federal Action Agenda represents our 18 Federal multi-agency collaboration to develop a working blueprint. This document outlines the important first steps that organizations within the Federal Partners Workgroup are taking. It describes time-limited, realistic priorities...and actions that can yield immediate results.
I have brought copies of the Action Agenda for you. Be sure and visit our web site for many more resources. I’ll give you that address at the end of my remarks.
The Action Agenda is our roadmap for realizing the vision of a transformed system…a mental health system that is driven by individual and family needs…a mental health system that focuses on building resilience and is centered on recovery. The transformed system will address the diversity that exists across individual and family needs in order to empower ALL individuals as informed "consumers" in a position to direct their own care...their own recovery.
It is a vision that moves the role of individuals and families far beyond simply participating in the system… they become the reason for the system. It is a dynamic idea and very different from the status quo.
[SLIDE 6: Consensus Definition of Recovery]
By definition, a system focused on recovery simply must integrate behavioral and primary health care. Mental health recovery "is defined as a journey of healing and transformation, enabling a person with a mental health problem to live a meaningful life in a community of his or her choice, while striving to achieve his or her full potential."
This definition is based on several fundamental principles. Recovery is a process that builds on the strengths of each individual. It is nonlinear and self-directed. It is holistic and person-centered, and involves personal and community respect, responsibility, and hope.
The process of recovery empowers consumers to make decisions that impact their lives. This process recognizes the valued role of consumers in supporting and encouraging others as they continue their own journey toward recovery.
The key to actualizing these principles of recovery is shared-decision making. This is an approach—used increasingly in general healthcare—wherein consumers and providers from all of the settings where consumers seek care work together to make informed decisions about healthcare options.
This definition of recovery changes our entire perspective on how we provide care because it implies a continuum of services.
The transformed system must integrate behavioral and primary health care. The linking of behavioral health with primary health care offers many benefits: Primary care providers are on the front lines in communities and often are the first and sometimes only contact consumers have with the health care system as early identifiers of behavioral health problems. We are working to better identify the barriers to the integration of these services, including the barrier of reimbursement for services.
Integration of primary care and mental health services is crucial to creating a seamless system of health care for all Americans. Provision of mental health services in primary care settings represents a first step to integrating care and increasing access to mental health services.
The primary care setting is often referred to as the "de facto mental health care delivery system."2 More than 65% of patients with mental health problems initially seek care in primary care settings.3
A particularly important diagnostic problem in primary care has to do with the co morbidity between mental and medical illnesses. Two-thirds of primary care patients with a psychiatric diagnosis have a significant physical illness.4,5
It is well established that chronic medical illnesses, taken as a whole, increase the likelihood of depression by two- to threefold.6
The primary care setting provides a valuable opportunity to improve access to mental health services.
At the same time, there are many barriers to the provision of mental health services in primary care settings. These barriers include attitudes, knowledge, beliefs, culture, training, stigma, and organizational constructs, such as financing policies that affect providers and patients alike.
The resolution of reimbursement and financial barriers has been identified by the Institute of Medicine and the New Freedom Commission as critical to improving access to and provision of mental health services in primary care settings.
Financial barriers include: lack of awareness of allowable payment mechanisms; divergent reimbursement mechanisms; mental health carve-outs that do not include or allow for payment of primary care providers (PCPs) or school-based providers in practitioner networks; payment for only a limited time with patients; state policies of not including some optional mental health coverage under Medicaid, and low reimbursement rates.
Other barriers that prevent those in need from getting screened, diagnosed, and treated include: lack of access to primary care providers; closed networks of providers; misunderstanding and misperception of covered services and reimbursement rules; lack of practitioners in rural or urban areas; lack of Medicare Parity; and lack of payment for the key components of the collaborative care model and team approaches to providing care.
We have been working diligently, at the Federal level, to overcome these barriers. We formed a collaboration among SAMHSA, the Centers for Medicare and Medicaid Services (CMS) and the Health Resources and Service Administration (HRSA) to work together, with input from research experts and stakeholder groups like the National Association of State Mental Health Program Directors (NASMHPD) and the National Association of State Medicaid Directors to clarify, collaborate and assist in education and technical assistance to promote the reimbursement of mental health services in primary care settings.7
In June, we convened an Expert Forum to identify barriers to reimbursement and strategies for overcoming these barriers. Attendees included individuals from governmental and non-governmental organizations, such as mental health consumer groups, primary care practitioners, public insurers, researchers, professional associations, health care systems analysts, state mental health and Medicaid directions, and managed care organizations.
2 Regier, D. A., Goldberg, I. D., & Taube, C. A. (1978). The de facto US mental health services system: a public health perspective. Arch.Gen Psychiatry, 35, 685-693.
3 Changing Profiles of Service Sectors Used for Mental Health Care in the Unite... Philip S Wang; Olga Demler; Mark Olfson; Harold A Pincus; et al The American Journal of Psychiatry; Jul 2006; 163, 7; Research Library pg. 1187
4 Bridges KW, Goldberg DP. Somatic presentation of DSM III psychiatric disorders in primary care. J Psychosom Res. 1985;29:563–569
5Spitzer RL, Williams BW, Kroenke K, et al. Utility of a new procedure for diagnosing mental disorders in primary care. The PRIME-MD 1000 study. JAMA 4;272:1749–1756
6Weyerer S. Relationships between physical and psychological disorders. In: Sartorius N, Goldberg D, de Girolamo G, Costa e Silva J, Lecrubier Y, Wittchen U, eds. Psychological Disorders in General Medical Settings. Toronto: Hogrefe & Huber; 1990:34–46
7A white paper was contracted for to provide background and a record of the multiple events. Reimbursement of Mental Health Services in Primary Care Settings was prepared by Danna Mauch, Ph.D. and Cori Kautz, M.A. of Abt Associates. This project was supported by the Center for Mental Health Services, part of the Substance Abuse and Mental Health Services Administration, and the Health Resources and Services Administration under Contract #HHSP2332005001289U.
[SLIDE 7: Barriers to Reimbursement]
The Expert Forum identified these seven priority barriers to reimbursement that I’m certain will be familiar to all of you.
The Forum’s suggested actions to address these barriers included: reimbursement policy clarification; government and stakeholder collaboration; provision of education and technical assistance; and consideration of additional services.
To improve reimbursement of mental health services in primary care settings, the Forum’s most frequently suggested action was the need to clarify statements, policies, definitions, and services, and broadly disseminate the clarifications. Clarifications must occur at a number of levels and within several federal agencies.
For example, they recommended the need to clarify the Medicare and Medicaid coverage of services and successful coding and billing practices, and same day services’ payment policies under those programs.
I’ll also mention that we are supporting the state Mental Health Directors’ Association as well as Medicaid Directors’ Association (NASMHPD and NASMD) to encourage each state to provide reimbursement for services for non-physician practitioners, and to promote services that are available and allowable under Federal Medicare and Medicaid guidelines.
The Expert Forum expressed that there is a need to widely disseminate and publicize the clarifications to payers, including state Medicaid agencies, state mental health departments, fiscal intermediaries contracted by the states and CMS, managed care organizations, practitioners, providers, including primary care practices, national and state organizations representing primary care providers, and through their newsletters and journals.
The Expert Forum also emphasized the importance of targeted collaboration among the Department of Health and Human Services agencies and national stakeholder organizations to support the provision and reimbursement of mental health services in primary care settings. Collaboration occurs when agencies and individuals have a desire to support and promote a particular mission, undertaking, or values.
They recommended, among other things, targeted collaboration to promote particular projects, such as examining the IMPACT collaborative care model, and providing a common definition of its components, documenting it as an "evidence-based practice" (EBP) model.
For effective collaboration to occur, the Forum acknowledged that each partner must dedicate time and resources to achieve the goals of the collaboration’s mission. Sustained collaboration among a variety of organizations and agencies with clear lines of accountability, responsibility, and tasks will improve the reimbursement of mental health services in primary care settings.
The Expert Forum identified education and technical assistance recommendations that cross settings, payers, and practitioner and provider types. They stressed that consistent information must be shared among states, the federal government, national non-governmental organizations, practitioner associations, payers, and others to improve reimbursement of mental health services in primary care settings.
For example, identifying, clarifying successful billing codes, and disseminating material on appropriate use of current Procedural Terminology (CPT) codes, such as Evaluation and Management codes versus Health behavior assessment and Intervention ( HBAI) CPT codes.
By educating, encouraging, and providing technical assistance, aligned with clarified information on reimbursement policies and practices, payers and providers are in a stronger position to change behavior and improve the reimbursement of mental health services in primary care settings.
Finally, the Expert Forum recommended the approval, authorization, and support of additional services and measures to improve the provision and reimbursement of mental health services in primary care settings.
They suggested the following changes:
- Link payment incentives to prevention, screening, and follow-up;
- Improve cross-setting integration through incentives for links and consultations between primary and specialty care;
- Increase individuals’ access to better supported and evaluated services; and
- Enlarge the workforce through telemedicine and use of allied professions. Allow reimbursement for consultation by telephone.
Funding is one of the most critical issues we can address at the Federal level, in addition to legislation and policy. Naturally, like most complex systems, there are many dimensions and I can only provide a very brief summary of the action taking place across the country...and internationally.
For example, in Colorado, they also had a demonstration site for the "Depression in Primary Care: Linking Clinical and System Strategies" project sponsored by the Robert Wood Johnson Foundation. The Colorado project was unusual in several ways. At the time the site became engaged in the project, it was already a participant in the MacArthur Foundation’s Re-Engineering Systems in Primary Care Treatment of Depression (the RESPECT Initiative).
In the RESPECT Initiative, Colorado Access worked with affiliated primary care clinics to use the PH Q-9 to screen for depression and used mental health clinicians trained as care managers, along with a supervising psychiatrist, to provide stepped care in collaboration with the PCP. Unlike most Medicaid health plans, it was also involved in the public mental health system.
Colorado Access presented their data recently—it represents 370 Medicaid patients, 81% female and 64% eligible under the Aged/Blind/Disabled aid code. The Colorado site achieved the following results:
- Savings of $170 per enrollee per month
- 12.9% reduction in costs in high-cost, high risk patients
- $2,040/year per patient savings
So, with 370 patients at a $2,040 savings per year…they acheived a $754,800 annual medical cost savings. The economic incentives for integration are there… even more importantly it enables a full spectrum of behavioral and primary health care for the consumer.
This is exemplified in a wonderful model that has been developed by the Canadian Collaborative Mental Health Initiative (CCMHI). It is an excellent example of "social transformation" at the tipping point. Notice how their framework parallels our work.
[SLIDE 8: CCMHI Model]
In the CCMHI report,8 they state that "collaborative mental health care is not a fixed model or specific approach; rather, it is a concept that emphasizes opportunities to strengthen the accessibility and delivery of mental health services in primary health care settings through interdisciplinary collaboration."
At the center of their Framework are the Consumer Goals: to increase access; decrease burden of illness; and optimize care.
In the outside ring, they place the four Fundamentals that determine the success and ease of implementation of collaborative mental health care:
- Congruent policies, legislation and funding regulations;
- Sufficient funds;
- Evidence-based research; and
- Community needs
And in the middle ring, they have placed four key elements of collaborative mental health care.
The first key element is Accessibility. The goals of collaborative mental health care are met by increasing accessibility to mental health services. This includes mental health promotion, illness prevention, detection, and treatment in primary health care settings, or "bringing the services closer to home."
The second element is Collaborative Structures. We must establish the systems and structures that support collaboration by defining coordinating roles. First, the structure will define the ways in which people have agreed to work together. It can be formal (service agreements, coordinating centers, collaborative networks) or informal (verbal agreements between providers). Secondly, providers will organize or create systems that will define how they agree to accomplish certain key functions of collaborative mental health care.
For example, these key functions may be accomplished through:
- Referral strategies—including forms, referral networks;
- The use of information technology—including electronic client records, Web-based information exchange, teleconferencing, videoconferencing, email, and list serves; and
- Evaluations—for example, developing evaluation instruments and agreeing to adopt certain evaluation instruments, methodologies and software in common.
A third central element of collaborative mental health care is Richness of Collaboration among health care partners, including: primary and mental health care providers, consumers and caregivers. Characteristics include knowledge transfer among health care partners through various educational initiatives and the involvement of health care partners from a wider range of disciplines- for example, nurses, social workers, dieticians, family physicians, psychologists, psychiatrists, pharmacists, occupational therapists, and peer support workers.
And finally, the fourth key element, Consumer Centeredness, calls for consumers, families and caregivers to be involved in all aspects of their care—from treatment choices to program evaluation—and for initiatives to be designed to address the needs of specific groups; in particular, those that are often underserved or have a great need for both primary and mental health care.
The Canadian Collaborative Mental Health Initiative has provided an excellent framework and a dynamic model of how our networks can connect...and how we can leverage our individual energies to create the synergy needed to fuel transformation.
I think it’s important to remember that people make up each part of the system—from the consumer in the center to the practitioners and providers in the middle ring and those of us in policy and research in the outer ring.
It’s the people that must make transformation happen. Transformation implies a structural, procedural, and even cultural makeover of an entire system, with far-reaching and long-term consequences. It is ultimately about newness—about new values, new attitudes, and new beliefs that are expressed in the changed behavior of people. The “people” aspect of transformation is crucial because we are its architects.
Benjamin Zander is the conductor of the Boston Philharmonic Orchestra. He and his wife have written a book called The Art of Possibility that I highly recommend.
The introduction begins with the concept of transformation.
8Gagne, Marie-Anik. What is collaborative mental health care? An introduction to the collaborative mental health care framework. Mississauga, ON: Canadian Collaborative Mental Health Initiative; June 2005. Available at: www.ccmhi.ca
[SLIDE 9: Zander Circumstances Quote]
The Zanders’ premise is that … "many of the circumstances that block us in our daily lives may only appear to do so based on a framework of assumptions we carry with us.
Draw a different frame around the same set of circumstances and new pathways come into view. Find the right framework and extraordinary accomplishment becomes an everyday experience." 9
Your own experience tells you that no level or branch of government alone can achieve the depth, breadth, and scope of needed change. Consumers and families living with mental health problems have complex, multiple issues. These issues cut across departments, agencies, and systems. Consequently, only systemic change…and change that is collaborative, coordinated, and consumer-needs-driven…will provide all that successful transformation requires.
Change, however, doesn’t simply happen. People must make it happen. The answers lie in leadership…at all levels so that we can identify and promote strategies that are successful in accomplishing our service directives. We can share as many solutions as challenges.
Each one of you has the power to be transformational leaders. Wherever you are in system you have the power to effect change. Change begins with the ability to see things differently and envision the possibility. You can’t change the world if you can’t change your mind.
What is the difference between the person that can make things happen and the one that is overwhelmed by the status quo?
The difference, I believe, is "commitment."
Commit comes from the Latin word committere, which includes in its definition this element of action: “to bring together, join, entrust, and do.
This idea is echoed by J.F.T. Bugental (Boo-gen-tall). In describing the essence of the commitment of a leader to a vision he wrote, "Commitment is, in a paraphrase, the statement, 'This I am; this I believe, this I do…'"10
You are the agents of transformation. Your role today, is to present your ideas, participate in the discussions, ask questions, challenge answers, network with new colleagues and share experiences with old friends.
We each have vital roles to play in the transformation. It will take all of our efforts and ingenuity to leverage the existing energy into the synergy that will accomplish the integration of behavioral and primary health care for everyone in the United States.
Winston Churchill once said, "To every man (and woman!) there comes a time in his lifetime, that special moment when he is figuratively tapped on the shoulder and offered that special chance to do a very special thing, unique to him and fitted to his talents. What a tragedy if that moment finds him unprepared or unqualified to do the work which could have been his finest hour."
The system needs to change. We are prepared, qualified and searching for the opportunity to do the work of our finest hour. We have the ability to combine vision, leadership and imagination to develop an understanding of the core business issues that our consumers are facing, along with the capability to formulate an action plan to integrate behavioral and primary care health coverage and provide the new health care system that we need for the new millennium.
"I invite you to join me in this commitment- right now… "This I am… This I believe… This I will do!"
Thank you!
9Zander, Rosamund Stone and Benjamin Zander. The Art of Possibility. New York: Penguin Books. 2002
10Bugental, J.F.T., as quoted by Hitt, D. Thoughts on Leadership. Cleveland: Battelle Press. 1992
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