Here is my response to a Request for Information from March, 2013. MA officials are hoping to integrate medical and “behavioral” health. Here it is.
- What behavioral health services should be provided in an integrated primary care setting? Describe changes to reimbursement policies that could be made to support the integration of the services you name.
- A primary care setting should be integrated with behavioral health services through greatly enhanced communication focused on an improved understanding of potential patient behavioral health issues coupled with a viable system of referral and ongoing dialogue.
- The principal behavioral health (BH) service that should be provided in primary care settings is an effective referral service for all behavioral health services. This service should be a user friendly web application that lists, by geographic area and insurer, providers of every service, availability, population served, insurances accepted, etc. Users should be able to sort by various criteria, including by insurance company, provider type, provider rating, location, handicap accessibility, etc. For example, a client needing a psycho-pharmacologist who accepts xxx insurance and is within walking distance of yyy. The system will allow client access, indication of need, fulfillment or non-fulfillment of need, rating of providers, and reporting of important summary data. This system should replace all existent individual insurance company systems and insurance companies should be compelled to enter their data into this new system.
- PCPs, other providers, educators, court personnel, etc can have this web application, outlined in more detail below, available in their office for discussion with patients to help consumers in finding appropriate referrals. Email to the provider can be generated on the spot. The system could allow consumers to give immediate permission for communication between the PCP and BH or other provider.
- Made possible by the above service, all current providers would be visible to the client and to each other and available for communication and collaboration (further description of needed service is below at #10).
- Such collaboration should be facilitated though the reimbursement by all insurers for collateral communication by phone, email, or other medium. Such communication could be noted, without detail, in the system to track communication. For example, “PCP Dr. X spoke to Psychotherapist Ms Y on (date)”.
- This system could allow communication between all providers. While PCP – BH communication can be important, so can other provider and stake holder communication. In the case of youth, it could include teachers, probation officers, DCF, DMR, DMH workers, mentors, etc, with appropriate access levels and permissions, since communication with those figures can be as or more important than communication with the PCP.
- What specific organizational structures or managerial strategies would help payers and providers work together to effectively integrate models of care that are person/family centered?
- Quality Behavioral Health services for youth cannot be provided without family and collateral communication with providers. Currently, this communication is not paid for by most insurers, effectively discouraging it. For example, MBHP pays for collateral communication for youth, BCBSMA, Tufts, UBH, and other commercial insurers do not. Appropriate reimbursement for time spent communicating is needed and may be the single most important thing that can be done to integrate models of care that are person / family centered.
- Currently, payers take varying levels of responsibility for making sure that all services are offered under their insurance. There should be monitoring of provider availability per insurer through a shared web application, and penalties levied for a lack of available BH or medical providers with an insurance network. This is the second most important thing that can be done to integrate models of care that are person / family centered.
- A statewide database and web application should be supported by referral service hotline should be established with authority to report and penalize insurers whose reimbursement or other policies cause them to be unable to provide access to a sufficient range of BH and medical providers. The current “tower of Babel” insurance system causes consumers, teachers, city and state workers, and other providers to be unable to find providers for certain insurances and services, to become discouraged, and to not be able to access needed care and services.
- Are there specific strategies for ensuring continuity of care without duplication of effort across the system and specifically between primary care and behavioral health providers?
- Continuity of provider is the most important and effective way to ensure continuity of care. Within behavioral health, this is especially true. There are many forms of relational therapy which rely on continuity of relationship. This continuity is constantly threatened by insurer limitation on number of sessions, enforced by insurer paid staff clinicians who look at diagnosis based data and who are encouraged by the insurer to say “no” to a statistically tracked number of supplicants.
- Additionally, consumers lose continuity when insurance or employer changes force a change of provider. Just as “pre-existing condition” will now have protection, so should “pre-existing relationship”. Insurers should have to reimburse consumers for providers who are out of their network due to employer or other induced change of insurer or insurance.
- To ensure continuity of care, track and penalize social service agencies that cannot sustain employment of staff due to poor pay and poor management practices. Have all agencies gather, submit, and publish staff retention data. Continuity of provider is currently in short supply, even though it is of great importance to youth who may see three different psychotherapists in six months, due to social service agency turnover. Perceived abandonment of young people, who already suffer from inadequate attachment, constitutes our own system of care traumatizing our own youth.
- Provide reimbursement for communication. Have identification of all providers and stakeholders be a standard aspect of all intakes, tracked in the system outlined below. Relevant medical health data should be automatically sent to behavioral health providers by PCPs based upon consumer and provider request. For example, “Johnny does a poor job monitoring his glucose level. All providers should be aware of this and see if they can be of assistance”.
- What challenges may impede the integration of primary care and behavioral health? Describe ways in which these challenges can be addressed through any means including changes in state regulation, standards and reimbursement policies.
- Insurance failure to reimburse for BH-PCP communication, family, and other collateral contact impedes integration. Behavioral Health workers need to communicate with all of the people who are crucial to the consumer, especially in the treatment of youth. Some stake holder communication can be even more important than the PCP, depending on the youth’s needs.
- Integration is also limited by problems with insurers and social service agencies within the Behavioral Health system itself whose agendas often fail to focus on and fulfill actual consumer needs and service. Reliance on a poorly fitting medical model and denial of a relational model form the philosophical backdrop for dysfunction. This is instantiated by most social service agencies focusing on productivity, useless mandated paperwork, and a mono-theoretical cognitive–behavioral treatment model. Many insurance companies, now in the name of cost containment, focus on profit and limiting service.
- These challenges can be addressed by reimbursement for communication, a.k.a. collateral contact. Social service agencies can be monitored for employee turn-over, the “canary in the mineshaft” of poor pay, practices, and client service. Mandated and mostly useless paperwork, much of it state agency inspired, can be slashed by 90%. A relational model, consistent with collaboration between consumers and providers as well as among providers, can be promoted through continuing education and an examination and modification of graduate school teachings. And insurance companies can be monitored for provider availability.
- What does ‘mental health parity’ mean to you and how can it be achieved in an integrated care model?
- “Parity” is a way to try to get the needs of behavioral health clients met. The real issue is whether clients will be able to find helpful providers and get the numbers of sessions they need with appropriate providers. Diagnosis is not an adequate means of determining need. Short term, evidence based therapies often fail to meet the needs of many clients, who need and seek a more relational model. Instead of “parity”, which is diagnosis based and threatens to invite a model of “X sessions for Y diagnosis”, “need” should be the standard, as defined by both the client and the clinician.
- How could consumer preferences/choice be achieved in an integrated model?
- For consumers to have choices, they need information from which to choose. Choice requires data, information upon which to make choices. A provider database web application, accessible to consumers, including a rating system for all providers and insurers should be created and maintained by the state and financed by the insurers, whose current policies create a cacophony of non-interoperable practices, policies, payments, number of sessions, deductibles, ways to renew, limitations, definitions of “medical necessity”, etc.
- An effective web based system could be available everywhere and could allow consumers to compare insurers, policies, and ratings, as well as those of providers. Consumers should be asked if their providers and their insurance are meeting their needs. Choice requires meaningful choices of consequence.
- Describe concretely any strategies, mechanisms and standards that have been or can be developed to protect the confidentiality and privacy of individuals, while allowing for the safe transmission of protected health care information in an integrated model of care. Do you have specific concerns about integrating behavioral health information in the primary care setting, and do you have any suggestions for addressing those concerns?
- I have many concerns about integrating behavioral health information in an integrated model of care. Behavioral Health and medicine should be coordinated, not integrated. Integration threatens patient confidentiality because it allows too many people access to records. Given that some consumers have a dozen providers, each of whom has several staff, this information cannot be adequately protected in an integrated system.
- Behavioral Health diagnosis is still stigmatizing in a way that medical diagnosis is not. Decisions about Behavioral Health information sharing should be made by the patient with recommendations to the patient by the clinician. I share information with doctors, teachers, lawyers, etc, only with the consent of my patient, as we both deem useful and appropriate.
- How should primary care providers be educated to recognize behavioral health conditions, to work with their patients in making appropriate decisions regarding referral to behavioral health services and to recognize the effect of medical conditions on individuals with serious mental illness?
- All licensed professionals have some sort of continuing education requirement. A behavioral health curriculum should be developed and made mandatory. It is crucial that this curriculum not be dominated by the advocates of short term, evidence based care, since much of this care is neither effective nor acceptable to consumers.
- Relational therapies and collaboration should be explained and advocated to professionals and educators in the same way that the importance of the patient– doctor relationship is now emphasized. Many relational strategies can be learned and practiced by PCPs and by other providers.
- What quality and outcome measures can be used to evaluate the successful integration of primary care and behavioral health services?
- Patient feedback and assessment is the only ethical, effective, and meaningful means of evaluation. Input from medical and behavioral providers is helpful, but the patient must be the arbiter and judge of his or her own care. Patient feedback can be integrated in the proposed referral system. Medical model outcome measurement systems based upon diagnosis and data from statistical outcomes surveys are fatally flawed in too many ways to explain here.
- Do you have any suggestions or comments regarding the integration of behavioral health with primary care that are not addressed by the preceding questions? If yes, please provide such suggestions or comments.
- The full integration of the various branches of medicine is vital, given that many medical interventions involve drugs that interact with other drugs, and physical test, protocols, and advice that must be consistent with other treatments and prescriptions. Behavioral Health, while crucial to patient well being, is not a branch of medicine, and has already been damaged by inappropriate attempts at integration, for which patients pay in quality of care.
- What is needed between medicine and behavioral health is good communication and collaboration, not physical or medical systems integration except in the proposed system. Caring for the psychological well being of consumers is the job of everyone. Behavioral Health (BH) practitioners should be leading those efforts through education, and advocacy focused on prevention and care.
- Referrals to all BH services should be readily available and accessible and BH training, by practitioners, should be mandatory for everyone in medicine, education, and other social services. Currently, experienced BH practitioners, predominantly female, are marginalized by insurance companies, social service agencies, and academia through the inappropriate application of a medical metaphor to what should be a relational enterprise.
- The biggest current problems in BH are the inability of consumers to find and access qualified providers and the ineffectiveness and poor current vector of much of Behavioral Health. These problems are caused by the chaos generated by multiple insurance companies with different, incompatible, and often incomprehensible systems of empanelling and identifying providers, as well as increased promotion of the medical model with accompanying often ineffective therapies.
- Many insurers seem driven by a profit system to deny service or to make access to service, to payment, and to attaining additional sessions, so difficult, that both consumers and providers give up. Some insurers use diagnosis within a medical model, to deny services to those needing them.
- Services for the poor, especially youth, are often funneled through private social service agencies. Many of these have long waiting lists due to low rates of insurer reimbursement, which results in low salaries to therapists and a high rate of employee attrition and consumer abandonment.
- Following a medical model, insurers and state agencies have created requirements for a monstrous, mandatory record keeping system, “the paperwork”, that adds almost no value to consumers, but creates a un-surveyed surveillance system and a “cover your ass” mentality, which the private agencies then impose on their hapless, dispirited clinicians. BH is a sickly bride for Primary Care.
- A well designed web application can greatly enhance productive communication and collaboration among BH providers, PCPs, nurses, all helping professions, and educators. I suggest that a secure web application be developed that has all providers listed with services offered or rendered, and consumer ratings of all participants. This program will allow consumers to search for providers, and for providers to see all other providers for any consumer. It will expose which insurers are lacking crucial providers. It will require providers to enter contact information, including at minimum, phone and email. It will allow providers, including primary care and behavioral health to communicate with each other easily, based upon consumer knowledge and consent. It will track communication that has occurred, but not what was discussed. It will allow consumers to register dissatisfaction at the lack of availability of an appropriate provider, so that a state agency can track which insurers fail to enroll an adequate array of quality providers. It could be coupled with a hotline for consumers. It will also allow consumers to rate providers for certain criteria, including “did the provider listen to my concerns, and address them with me” and “did my provider communicate with other providers as needed”.