Front Matter

Contributors

Preface

Introduction

1 DEFINING AND MEASURING VALUE

2 EVOLUTION OF FUNDING AND QUALITY CONTROL IN HEALTH CARE

3 THE CURRENT SYSTEM: THE MESS WE ARE IN

4 SOCIAL DETERMINANTS OF HEALTH

5 SUCCESSFUL APPROACHES TO INCREASING VALUE

Part II Where We Want to Go Systems Interventions

6 INNOVATIVE FINANCING: INCENTIVIZING VALUE

7 INTEGRATION OF SERVICES

8 PREVENTION AND HEALTH PROMOTION

9 PEER AND RECOVERY SUPPORT SERVICES

10 APPLICATIONS OF TECHNOLOGY

Part III Where We Want to Go Professional Interventions

11 AN EXPANDED ROLE FOR PSYCHIATRY

12 PSYCHIATRIC WORKFORCE DEVELOPMENT

13 PHARMACEUTICAL MANAGEMENT AND PRESCRIBING

14 DIAGNOSTIC REFORM

15 ADVOCACY

16 PSYCHIATRIC LEADERSHIP

17 ADDICTION TREATMENT AND HARM REDUCTION

18 IMPACT OF CLIMATE CHANGE

19 INCARCERATION REFORM

20 HEALTH AND THE WORKPLACE

21 AGING AND END-OF-LIFE CARE

22 A VALUE VISION FOR HEALTH CARE REFORM

Index

Medical Director, Behavioral Health, Northwell Health Solutions, Manhasset, New York

General, Addictions and Forensic Psychiatrist

Associate Director for Education, South Central MIRECC; Director, Geriatric Psychiatry Fellowship; Associate Professor, Baylor College of Medicine, Michael E. DeBakey VA Medical Center, Houston, Texas

Chief of Quality and Clinical Innovation, Connections Health Solutions; Associate Professor of Psychiatry, University of Arizona, Tucson, Arizona

Assistant Professor of Psychiatry, Albert Einstein College of Medicine, Bronx, New York

Medical Director of Behavioral Health, Sulzbacher Center, Jacksonville, Florida

Chief Psychiatrist and Medical Director, Novadic-Kentron, Centre for Addiction Treatment, Vught, The Netherlands; Affiliated Researcher, Department of Psychiatry, Amsterdam University Medical Centers, Amsterdam, The Netherlands

Medical Director, Acute Recovery Center, Edward Hines, Jr. VA Hospital, Hines, Illinois; Affiliate Associate Professor, Department of Psychiatry and Behavioral Neurosciences, Loyola University Chicago, Maywood, Illinois

Behavioral Health Consultant, Cincinnati, Ohio

Psychiatrist, Centre for Addiction and Mental Health, Toronto, Ontario, Canada

Vice President, Program Services, Coordinated Behavioral Care, New York, New York

Associate Professor, Department of Psychiatry, University of Nevada School of Medicine, Reno, Nevada; Medical Director of Behavioral Health, Carson Tahoe Regional Medical Center, Carson City, Nevada; Chair, Climate Committee, Group for the Advancement of Psychiatry, Dallas, Texas

Medical Director of Outpatient Services, Skyland Trail; Adjunct Assistant Professor, Emory University School of Medicine, Atlanta, Georgia

President, FTF Consulting LLC, Bluffton, South Carolina

Child and Adolescent Psychiatry Fellow, Clinical Instructor, New York University School of Medicine, New York, New York

Attending Psychiatrist, Corporal Michael J. Crescenz VA Medical Center; Clinical Assistant Professor of Psychiatry, Perelman School of Medicine, Philadelphia, Pennsylvania

Vice Chair for Education, Professor of Psychiatry and Behavioral Science, and Director, Division of Geriatric Psychiatry and Training Program, Montefiore Medical Center, Albert Einstein College of Medicine; Department of Psychiatry and Behavioral Science, Montefiore Medical Center, Bronx, New York

Clinical Assistant Professor, Mt Sinai School of Medicine, New York, New York

Kennedy-Leavy Professor of Psychiatry, Department of Psychiatry, Columbia University, New York, New York

Associate Professor of Psychiatry, Emeritus, Washington University Medical School, St. Louis, Missouri

Resident Physician, UCLA-Olive View Psychiatry Training Program, Sylmar, California

Clinical Assistant Professor of Psychiatry, University of Texas Medical Branch, (UTMB), Richmond, Texas; Clinical Director, Jester-IV Unit, UTMB-Correctional Manage Care (UTMB-CMC)

Associate Professor, Department of Psychiatry and Neurobehavioral Sciences, University of Virginia, Charlottesville, Virginia

Residency Program Director, PGY2 Psychiatric Pharmacy Residency Program; Clinical Pharmacy Specialist—Psychiatry, Michael E. DeBakey VA Medical Center; Assistant Professor, Baylor College of Medicine, Department of Psychiatry and Behavioral Sciences, Houston, Texas

Chief, Peer and Allied Health Professions, Los Angeles County Department of Mental Health, Los Angeles, California

Chief, Avance Psychiatry and Adjunct Professor of Psychiatry, Rush University Medical Center, Raleigh, North Carolina

President/CEO, Coordinated Behavioral Care, New York, New York

Clinical Professor of Psychiatry, Department of Psychiatry, Columbia University Medical Center, New York, New York; Senior Advisor to Community Psychiatric Nurse Practitioner Fellowship, Community Healthcare Network

Clinical Assistant Professor, Department of Psychiatry, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin

Chief Medical Officer, Population Health–Behavioral Health and Director, Population Health Education, University Hospitals; Director, Public and Community Psychiatry Fellowship, Case Western Reserve School of Medicine, Cleveland, Ohio

Professor and Chair, Department of Psychiatry and Behavioral Medicine, Brody School of Medicine; Director, Center for Telepsychiatry and e-Behavioral Health, East Carolina University; Executive Director, North Carolina Statewide Telepsychiatry Program, Greenville, North Carolina

Executive Director, Behavioral Health Service Line, Northwell Health, Manhasset, New York; Clinical Assistant Professor of Psychiatry, Hofstra University, New York

Staff Psychiatrist, Louis Stokes Cleveland VA Medical Center; Assistant Professor, University Hospitals Cleveland Medical Center, Cleveland, Ohio

Associate Professor of Psychiatry and Behavioral Science and Associate Director, Geriatric Psychiatry Training Program, Montefiore Medical Center, Albert Einstein College of Medicine; Department of Psychiatry and Behavioral Science, Montefiore Medical Center, Bronx, New York

Vice President, Care Coordination Services, Coordinated Behavioral Care, New York, New York

Clinical Professor of Psychiatry, University of Maryland; Past President, Group for the Advancement of Psychiatry; Past President, American Psychiatric Association; President Emeritus, Sheppard Pratt Health System, Baltimore, Maryland

Chief Medical Officer, Philadelphia Department of Behavioral Health and Intellectual disAbility Services, Philadelphia, Pennsylvania

Clinical Professor of Psychiatry, University of Pittsburgh Medical Center; Director, Center for Public Service Psychiatry, Western Psychiatric Hospital, Pittsburgh, Pennsylvania

Director, Student Mental Health and Wellness; Assistant Professor, New York Medical College, Hawthorne, New York

Executive Medical Director, Medical Affairs, Alkermes LLC, Waltham, Massachusetts; Associate Professor of Clinical Psychiatry, Columbia University, New York, New York

Assistant Professor, Department of Psychiatry, Columbia University, New York, New York

Medical Director, Didi Hirsch Mental Health Services, Culver City, California

Health care in the United States costs too much and is of very uneven quality, and many individuals cannot access the care they need. The crisis of health care in the United States is a chronic problem that has persisted for decades, and because of vested economic interests and the polarizing politics of the twenty-first century, solutions, even the simplest ones, allude us. For psychiatric care, as well as more broadly conceptualized behavioral health care, the situation is more ambiguous and in some ways more critical. The investment and costs of behavioral health care, in contrast to general health care, are much more modest and in many sectors significantly lower than what is necessary. The low investment in behavioral health care contributes to the overall poor value of our health care system, because many of the high costs and poor outcomes in general health care are a direct result of lack of access to psychiatric treatment. Furthermore, we do not fund basic preventive actions that focus on mental health, such as regular exercise, nutrition, violence reduction, and education. These deficits are indicative of the stigma associated with mental illness and the devaluation of mental health care. Payers often resist paying for this care by questioning the “necessity” of treatment. Employers often discount the legitimacy of mental disability and often terminate employees with decreased productivity due to mental illness.

Both patients and doctors suffer in the U.S. scenario. Patients and their families have had to take on a greater share of the burden of expensive treatment due to high deductibles, large copays, and limited coverage. Clinicians are harassed with multiple regulatory requirements, burdening them with extra paperwork and time-consuming electronic health records, and high expectations for productivity in our fee-for-service environment.

The U.S. health system compares poorly with the rest of the world on every metric of health as well as cost. Our outcomes are significantly worse. Compared with other developed Western democracies, our costs are two to three times higher. Prices are extraordinarily high in the United States for virtually every health care “product.” An outside observer is struck by the fact that health care is not considered a right or a public service in the United States. As former CEO of Sheppard Pratt, the largest not-for-profit behavioral health system in the country, I marveled at our difficulties in collecting payments for essential behavioral health services at the same time that our special education services were reimbursed well. Education is considered a right in the United States. Health care is not.

In the United States, we have a mixed system of both public and private financing. The profit motive has placed additional burdens on the effectiveness and efficiency of health care. Extraordinary waste abounds in the U.S. health care system, ranging from two to four times that of other developed nations. To collect the bills at Sheppard Pratt, we had to employ several dozen individuals to interact with hundreds of insurance companies with complex copayments and rules for coordination of benefits. On top of that, our clinicians had to contend with managed care reviews, which often took many hours to avoid denial of payment.

This volume, superbly edited by Wesley Sowers and Jules Ranz, emphasizes that the value of psychiatric treatment and mental health care goes beyond the individual patient. The impact of limited access to mental health treatment on family, community, and the population at large has never been quantified adequately to justify to policy makers the major public and private investments in care and prevention. The value of mental health treatment for medical well-being and reduced medical costs, as well as quality of life, has a growing research base. This work is quite enticing as we think about value. Increased productivity of the nation’s workforce is also an area of much promise in establishing the value of mental health treatment. Improving the interface between corrections and mental health is yet another way to enhance the value equation.

With its focus on value, this volume makes an excellent diagnosis of our ailing health care system. With a special focus on psychiatry and behavioral health care, it also suggests actions that can change our dysfunctional health care system for the better. Each chapter is written by leaders from the Group for the Advancement of Psychiatry, referred to as “America’s think tank for mental health,” and others who are deeply concerned about the experience of clinicians, individuals, and families as they endeavor to access quality health care and pay for these services. In addition to making a diagnosis, this volume provides a menu of reforms, both large and small, that would improve the experience of patients, improve outcomes, lower costs, and make the practice of psychiatry more fulfilling. Psychiatrists can provide transformational leadership in the current environment for care, and even more so in the future. However, psychiatrists cannot do this alone. They must work closely with other medical colleagues as well as nonmedical leaders in systems of care that have a close relationship to the process of recovery in the community. Employment, income support, and housing address the social determinants of illness and health that are strategic for individuals with mental illness and addiction. Working with peers and self-help are other key components for the change that is necessary to improve the value equation. Our advocacy is needed more than ever.

We know we can do better. A lot better. Read this book and see how.

This book is the product of the Mental Health Services Committee (MHSC) of the Group for the Advancement of Psychiatry (GAP). GAP is an organization of thought leaders in many branches of psychiatry, and the MHSC is one of 32 standing committees focused on a wide array of topics. As its name implies, MHSC has a broad mandate, and over the years it has directed its attention primarily toward issues related to systems of education and service provision. In the past 15 years, the committee has carried out several projects, and its findings or positions have often been published in one form or another.

One of the projects that occupied the committee from 2006 to 2014 was an attempt to define the role of psychiatrists in mental health systems. An article published in 2006 (Ranz et al. 2006) used American Psychiatric Association data to demonstrate that psychiatric practice has increasingly been taking place in publicly funded settings, as opposed to private practice. The article suggested that this trend demanded an examination of how psychiatric residents are being prepared to work in organizational settings.

In 2012, the MHSC described the extent to which psychiatric residents at 12 sites across the country were being trained in systems-based practices (Ranz et al. 2012). The study suggested that systems-based practices could be described by four factors, which the committee converted into four roles named 1) patient care advocate, 2) team member, 3) information integrator, and 4) resource manager. In 2014, the committee published a qualitative analysis of the residents’ experience with the training they were receiving in systems-based practices and found that it was usually quite limited. The committee continued to examine the implications of these findings, with emphasis on the role of resource manager. It concluded that training to perform in this role was being seriously neglected (Arbuckle et al. 2014; Fried et al. 2014).

In addition to working on this long-term project, the committee developed several other interests between 2008 and 2016. One subgroup began to put together a pamphlet on career development stemming from a concern over the lack of satisfaction experienced by many psychiatrists who found themselves in jobs that did not coincide with their values and career expectations. A related topic taken up by the committee was the reduction in the scope of psychiatric training and practice, at the expense of developing skills in clinical activities such as individual, group, and family therapies. Another subgroup explored the ways and circumstances in which psychiatrists should provide primary care to the patients they serve (Sowers et al. 2016). The committee also explored ethical issues related to the misuse of diagnoses to access entitlements, and by extension, the meaning and usefulness of the current diagnostic system. A consideration of prescribing practices included the relevance of cost in the process, as well as pharmaceutical industry influence in clinical decision making (Barkil-Oteo et al. 2014).

In the early part of 2017, the MHSC began to consider future directions and ways to link the projects that had been explored in the preceding years. In doing so, a common theme began to emerge. All of these activities were related to improving the quality and/or the cost of the care that our systems deliver. They also fit well with our exploration of the role of psychiatrists as resource managers. Discussions took place in the context of growing recognition of the Triple Aim, introduced by Berwick and colleagues (2008) at the Institute for Healthcare Improvement. Triple Aim initiatives are designed to 1) improve the experience of care, 2) improve the health of populations, and 3) reduce the per capita costs of care for populations. Improving the experience of health care providers was later added as a fourth aim (Berwick et al. 2008; Institute for Healthcare Improvement 2017).

These concepts coalesced and led the committee to consider the need to elaborate them more clearly for issues related to emotional health. As it further researched the topic, the MHSC became aware that very little had been written on this topic or the role of psychiatrists in promoting value-based care. As a result, the decision was made to undertake the writing of this book.

In the first chapter of this book, we attempt to define value. The word value is commonly defined as outcomes divided by costs. This quotient can be calculated through the collection of data on specific measurements. However, a less tangible aspect of value also exists but is not so easily measured. It is sometimes described as “social value” or the well-being of society. Measurements of social goods are not always coherent or easily agreed upon and will often shift when considered by various stakeholder groups. We have attempted to include both aspects of value determinations in our writing and to consider them from various viewpoints. Throughout the book you will see this interplay between these two concepts of value and the clash between the interests of various constituents of the health care system.

The other concept that emerged during the writing of this book was the interdependent relationship between emotional health and physical health. These two aspects of health have an inseparable impact, and attempting to consider mental health independently would have been counterproductive. As a result, in many cases our research led us to consider value in the context of the health care system in general, and think about how its structure impeded the achievement of value throughout.

Part I of the book, titled “Where We Have Been,” provides a historical overview of the forces that convinced us that this book would be a useful addition to the ongoing discussion of seeking value in U.S. behavioral health care. The chapter authors consider the origins of the disjoint systems of care that currently exist and provide some comparative information about the U.S. system relative to those of other developed nations. The impacts of social and political determinants of health in this country are also considered in this section, along with some of the initiatives that have actually improved the value of services in behavioral health to date.

Part II, “Where We Want to Go: Systems Interventions,” focuses on correcting the flaws in our current fragmented systems. Important aspects of a solution include rethinking the way we finance health care, considering the role of market forces, and creating the right balance of financial incentives, along with changing the priorities and structures of our systems that have led to the poor health outcomes this country has experienced. Additional elements of needed change that are discussed are integration of services, prevention and health promotion, development of a peer workforce, applications of technology, and elimination of administrative waste.

Part III, “Where We Want to Go: Professional Interventions,” turns attention to many of the enhancements that can be achieved without radical change in the systems in which services are provided. It pays particular attention to what the psychiatric profession and individual psychiatrists can do to improve value in these systems. Expansion of consultative roles, provision of the skills needed, alliance with other professionals and teamwork, reform of our diagnostic systems, cost consciousness in prescribing, advocacy, and leadership initiatives are all considered as interventions that can improve the value we seek.

Part IV, “Special Value Opportunities,” discusses a variety of opportunities to improve population health and social well-being in areas of policy and practice that go beyond the typical role of clinicians and health care administrators, and in many cases beyond what we normally think of as health care. Harm reduction to address addictions, interventions to mitigate the impact of climate change, elimination of counterproductive incarceration practices, incorporation of healthy practices in the workplace, and reconsideration of care at the end of life all have ramifications for the reduction of social costs and population health that extend beyond their immediate, tangible health advantages.

The final chapter, in Part V (“Conclusions”), serves as an attempt to integrate the recommendations made throughout the book into a coherent framework or “vision” for health care reform. We recognize that the ideal is not always attainable in the short term, and that compromises may be needed to achieve an incremental reform that can eventually lead to the “best balance.” The chapter presents some strategies and structures to help guide future reform efforts.

We recognize that a book of this type is rarely read straight through, from cover to cover. Each chapter is designed to stand on its own and to provide a coherent perspective on the topic it tackles. As a result, there is a small amount of unavoidable redundancy in some of the chapters. For example, while there is no chapter specifically dealing with depression, it is referred to in many of the chapters in this book. In many cases, when overlap occurs, readers will be referred to other chapters that contain a more complete treatment of the issue. Although we have attempted to provide a comprehensive view of problems and possibilities related to high-value systems of care, it is likely that we have missed some opportunities. It is our hope that psychiatrists, and other behavioral health practitioners, who read this book will participate in the search for value, which is arguably the most difficult challenge we face, and fill any gaps we have left. We hope that all readers will be inspired to delve further into processes that create value and that these pages will be useful to those who advocate for the changes that are so badly needed in the U.S. health care systems.

Andres Barkil-Oteo, M.D., Joseph Battaglia, M.D., Colleen Bell, M.D., Glen Davis, M.D., Bruce Fage, M.D., Joanna Fried, M.D., Elizabeth Janopaul-Naylor, M.D., Michelle Joy, M.D., Nubia Lluberes, M.D., Hunter McQuistion, M.D., Jules M. Ranz, M.D., Manish Sapra, M.D., M.M.M., Deepika Sastry, M.D., Sunmolu Shoyinka, M.D., Mardoche Sidor, M.D., Anna Skiandos, D.O., Wesley E. Sowers, M.D., Michael J. Vergare, M.D., Donovan Wong, M.D.

Special thanks to Sara Hamel for her editorial assistance.