Psychiatric Services, Integrated Care, and San Francisco

I hope that by the time this column is in print, the partisan wrangling over the budget in Washington is at least no longer at a fever pitch. But the stakes in the current economic and political drama in our country are very high—for our patients, and for all of us as well. I think most Americans would agree that health care reform is a top priority, but how to make it happen is not so easy to figure out, especially in an economy still in a shaky recovery process. But psychiatry must be at the table, since psychiatric disorders are prevalent and top the charts of all medical conditions that lead to disease burden and disability.

Recently, for example, the National Quality Forum gathered a group of medical experts to rank order 20 high-impact conditions that account for 95 percent of Medicare costs—these conditions included Alzheimer's, atrial fibrillation, breast cancer, diabetes, congestive heart failure, stroke, major depression, and many more. After prioritizing the list based on dimensions like cost, prevalence, and improvability, major depressive disorder was ranked first, many points higher than all of the other conditions, including the second on the list, congestive heart failure.

We need to identify more cost-effective models of care, but only if they also improve the quality of that care or at least don't make matters worse. If we can't devise new models that save money and improve care, then we must be extremely cautious, since reducing expenses in one area may result in unintended increases in expenses elsewhere. This risk is illustrated in an interesting paper by McFarland and Collins in the August Psychiatric Services, which tracked patterns of care for patients with schizophrenia following Medicaid reductions in Oregon. There was a marked increase in (costly) state hospitalization for patients who lost coverage compared with those who did not.

You've heard me talk a lot about integrated care, which I believe could lead to more cost-effective and better care for our patients. A good example of this concept was described in another recent paper by Wayne Katon and colleagues in the December 30, 2010, New England Journal of Medicine. Patients with poorly controlled diabetes, coronary artery disease, and depression were randomized to receive either guideline-based collaborative care management or routine care by medically supervised nurses working with primary care physicians. After 12 months, there was greater improvement in all outcome measures (hemoglobin A1C, low-density lipoprotein, cholesterol, systolic blood pressure, and Symptom Checklist-20 depression scores) in the collaborative care group than in the usual care group, and there were more frequent adjustments of insulin and antidepressant medications, better quality of life, and greater satisfaction with care for diabetes, coronary heart disease, and depression.

This has been a long-winded introduction to my main message in this column: make your plans now to attend the 63rd Institute on Psychiatric Services in San Francisco in October! You may not know that after I had selected "Integrated Care" as my presidential theme, Dr. Wes Sowers, chair of the institute's Scientific Program Committee (SPC), called and, without knowing what I had picked, suggested "Integrated Care" as the theme for the 2011 institute, so we were already aligned.

The SPC chose "Comprehensive and Coordinated Care: Bringing It All Back Home" as the exact title for the meeting, and the program is chock full of great sessions. There is a designated Integrated Care Track that includes lectures, courses, symposia, workshops, and innovative programs, and there will be opportunities for interactions with primary care physicians at the meeting. Presenters include Ron Diamond, Anita Everett, Andrea Fox, Roger Kathol, David Pollack, Lori Raney, and many more. In addition, there will be special presentations by Carl Bell, Richard Frank, Tom Kosten, Patrick McGory, Mark Olfson, and Wilma Townsend—again, just to mention a few of the players in a terrific lineup.

What the program says to me is that our members are intensely interested in learning about and being active participants in the efforts to improve health care in our country, but it remains clear that we have a lot of work to do.