On April 3, the Massachusetts Medical Society (MMS) presented its 9th annual public health leadership forum titled “Mental Health: Achieving Parity in Principle and in Practice.” A cross-section of noted clinicians and administrators in mental and public health painted a dire picture of existing conditions and offered suggestions for improving the landscape.
In his opening remarks, Richard V. Aghababian, M.D., MMS president, drew attention to recent violent events related to mental health, specifically the shooting at Newtown, Conn. and emphasized the importance of establishing a relationship between public health and mental health.
To illustrate Aghababian’s point, Jeffrey S. Wisch, M.D., clinical director, Vernon Cancer Center, acting chief of hematology/oncology and director of inpatient oncology at Newton-Wellesley Hospital, and associate clinical professor of medicine at Tufts University School of Medicine, offered a personal reflection on what he called a “broken system.” He related the story of sitting in an emergency room for hours with a 19-year old family member with severe depression; the youth was seeking admission but needed approval from the insurance company. Once this approval finally happened, no beds were available.
As a physician, Wisch expressed his frustration with the system. “I don’t need approval to admit or treat or discharge. Would a patient with chest pain be told they couldn’t be admitted because they were not yet having a heart attack?” he asks. “Mental health is where cancer was in the 1950s. The ER staff doesn’t know what to do with someone with emotional problems. There is no coordinated care going forward, no chronic rehab facility, no visiting nurse or case worker.”
To develop a more cohesive and collaborative system, the Substance Abuse and Mental Health Services Administration (SAMHSA) created a regional system that collaborates with local Health and Human Services departments to educate and engage the public and key stakeholders in the agency’s vision of public health reform. Kathryn Power, M.Ed., administrator for region one, which includes all of New England, points out that SAMHSA focuses on four key messages, specifically that behavioral health is essential to health; prevention works; treatment is effective; and people recover.
To achieve these goals, SAMHSA has devised a strategic initiative that includes block grants and the promotion of community-based services, focusing on coordinating primary care with specialty care and prioritizing prevention and quality rather than quantity of care.
Power expressed optimism regarding the Affordable Care Act (ACA), which has designated parity as its keystone. The creation of health homes, accountable care organizations (ACOs), patient safety initiatives in hospitals and quality measures for at-risk populations is a major step in the right direction toward equal treatment for those with mental illness, she says.
The economic side of parity came under discussion from Richard G. Frank, Ph.D., Margaret T. Morris Professor of Health Economics, Department of Health Care Policy at Harvard University Medical School. He notes that the government spends $329.28 billion every year on mental health-related care. “Most of the money has nothing to do with services,” he says. “How we are spending the money and how we can spend it more on services is the question.”
While Frank applauded the government’s efforts to achieve parity, he cited problems with the existing legislation. “This is regulation by analogy,” he says. “Does the service in mental health and substance abuse have comparable service on the medical surgical side?”
According to Frank, 40 percent of those under 65 have severe and persistent mental illness. Although studies on these individuals are not definitive, he does see “green shoots,” i.e., reasons for optimism. Specifically, he applauds the $100 million the government has earmarked for health care integration. “This is the biggest deal we’ve seen in mental health care ever. It’s of historical proportion and twice as important for substance abuse diagnoses. The infusion of new funds will be transformative,” Frank says. “We can’t get distracted by small stuff. We have to put the new money to work in a way to benefit the patient and not shortchange him.”
Mark Perlmutter, M.D., FACEP, chair and vice president of Emergency Network Services for Steward Health Care and associate professor of emergency medicine at Tufts University School of Medicine, addressed the on-going problem of overcrowded emergency departments where one in 21 patients presents with a mental health diagnosis. “The ED is not a locked unit, not a therapeutic milieu. The physicians don’t see these patients [immediately]. They become boarders without doctors,” he says.
Perlmutter decried the “bankers’ hours” that insurance carriers hold; patients should not have to await admission approval for hours, which is often the case, he says. He suggests rapid cycle interventions, higher reimbursement rates for certain patients and incentivizing insurers as partial solutions. “We need more transparency. We need more pilot programs to remove the silos,” says Perlmutter. “In Massachusetts, there is a lack of access and an increased demand, so the burden of care falls on the ED.”
Peter Metz, M.D., clinical professor of psychiatry and pediatrics at the University of Massachusetts Medical School, cites the System of Care, a federally supported framework for enhancing the behavioral health delivery system for children. This program is “family driven and youth guided, breaking down the silos and providing relevant services,” he says. “It’s a family partnership at all levels of the system. It’s a community-based coordination of care, culturally and linguistically competent.” The goal of the program is to identify the strengths and weaknesses of the family, uncover what is unique and then measure the outcomes, Metz adds.
Metz believes in making “families feel they’re part of the solution.” One program that includes families is the Children’s Behavioral Health Initiative (CBHI), which serves eligible youth under 21 who have MassHealth. This program offers intensive care coordination of wraparound services; outpatient, in-home and behavior management therapy; therapeutic mentoring; family support and training; and mobile crisis intervention.
To wrap up the meeting, Ken Duckworth, M.D., medical director for the National Alliance on Mental Illness (NAMI), raised the issue of teens at risk. While preparing for his presentation, he asked his 16-year old twin daughters for advice on engaging teens in mental health advocacy. When they responded by showing him a YouTube video of “The Shake,” an international dance craze, he realized that belonging and developing an identity is crucial to teen development. “Kids have developing brains and life can be overwhelming. Kids with genetic vulnerability are at high risk for psychoses,” he says. Calling Massachusetts a “patchwork of care systems,” he notes a need to “find ways for young people to be part of a normal developmental flow.”
By Phyllis Hanlon