Behavioral Health

Want to improve public health? Start with housing.

A well-worn axiom says that “hope is not a plan.” Indeed, hope alone is such a hands-up abdication of planning that editor Thomas Mowle was inspired to use the phrase as the title of his 2007 book of essays on the war in Iraq, which says something.

Still, if we play with syntax and add a few words, we can say that every successful plan should offer a measure of hope—hope for success, an improved reality, greater opportunity.

With the twin American scourges of homelessness and addiction, hope starts with a plan that includes housing—a refuge, even if it’s just a 50-square-foot wooden box.

“Housing is one of the best-researched social determinants of health, and selected housing interventions for low-income people have been found to improve health outcomes and decrease health care costs,” writes Lauren Taylor in Health Affairs.

Perhaps, then, housing is a key component in the overall explanation for why health and life expectancy have been declining in America the last few years. When workers making minimum wage—more than 20 million people and roughly 30 percent of all hourly, non-self-employed workers over 18—can afford a modest one bedroom home in only twelve counties in the country, it’s near impossible to argue that the gap between wages and housing costs does not create profound desperation and instability.

That despair, in turn, worsens public health in myriad ways. People with no hope turn to drugs and alcohol, battle depression, eat poorly, work three jobs to exhaustion and injury, battle chronic pain with no viable options, sleep too little, etc. And in worst case scenarios, they end up on the street with few if any possible good outcomes.

Is it the housing as an end that creates better public health outcomes? Not really. No one who lacks adequate housing or has to move frequently is clamoring for a 7,000-square-foot home.

Instead, it’s the benefits housing provides that support a healthier, more sustainable life. As an essential social determinant of health, well-built and well-conceived housing is one corner of foundation supporting four interconnected quality of life pathways: stability, quality and safety, affordability, and community. If any of these pathways are lacking in the housing options available, housing potentially becomes a negative social determinant of health.

For example, consider the tiny homes many cities are now building to try and grapple with the problem of homelessness. Initially, it seems like any kind of lockable structure is an improvement on doorways, park benches and even shelters. But in some cities, tiny houses don’t come with heat, electricity and plumbing, effectively making clusters of houses a small step up from homeless encampments. As social determinants of health, they still register a negative, leaving America far from realizing the goal of housing as net positive for all citizens.

Of course, housing is only one social determinant of health, which collectively are generally lumped as social and environmental factors (20 percent), genetic fortune or misfortune (30 percent), and individual behavioral choices (40 percent).

The final 10 percent is healthcare, and maybe that percentage seems a little light, given how much attention we pay to the healthcare system. Still, think about the ability of healthcare to balance all other social determinants—diet, housings situation, employment status, mental status—when they’re decidedly or even predominantly negative.

It’s not hard to see why clinicians resent being held responsible for the fire after the house is engulfed in flame.

And what, if anything, can healthcare do about these social determinants over which they have no control? In short, look for solutions and shortcuts.

Comprehensive medical records, interoperable systems, healthcare data exchanges and the like can together enable hospitals and clinicians to circumvent the complications created by a transient life. But healthcare providers and organizations can also address social determinants of health more directly.

“The health care sector should continue to explore the extent to which home interventions, such as the well-studied community asthma initiatives, can make financial sense among other patient populations,” says Health Affairs writer Taylor. “Given the shift toward accountable care models and other value-based payments, the financial incentives for health care systems to take broader responsibility for social determinants of health (including housing) are likely to increase.”

And that’s the added factor that may motivate healthcare organizations as much as anything else. Housing makes communication with patients more reliable, which cuts down on the costs of care and lends stability that enables accountable care. Really, all social determinants on the positive side of the ledger decrease healthcare costs, but stable housing makes the others that much more likely.

The social determinants of health are also lurking in the national discussion of universal healthcare. At times, the nation and the industry seem caught up in discussions of payment models, insurance deductibles and technological advancements. Maybe we miss the fact that having affordable healthcare is better than not having it in the same way that having a 200 square-foot house with locks is better than living on the streets, even if we can agree that such basic standards are not enough.

Using social determinants, we could improve the health of many Americans without ever specifically addressing a medical record or length of stay. And until we do see patients as a complex amalgamation of influences, we can’t be surprised that specific therapies out of context have negligible impact on overall public health.

Irv Lichtenwald is president and CEO of  Medsphere Systems Corporation, the solution provider for the CareVue electronic health record.

Is specialization another factor in deteriorating mental health care?

"A human being should be able to change a diaper, plan an invasion, butcher a hog, conn a ship, design a building, write a sonnet, balance accounts, build a wall, set a bone, comfort the dying, take orders, give orders, cooperate, act alone, solve equations, analyze a new problem, pitch manure, program a computer, cook a tasty meal, fight efficiently, die gallantly. Specialization is for insects."

 - Robert A. Heinlein

In almost every walk of life, we worship at the altar of specific expertise. It makes sense. Who, after all, doesn’t want a brilliant legal defense, a witty and erudite professor, a perfectly chewy bagel?

The division of labor drives how we pursue education, get paid and find professional and personal satisfaction. Sometimes, however, it also creates blinders that make it hard to see challenges lurking just off stage.

Take healthcare, for example, and the myriad things that can go wrong with the human body. Is American healthcare treating individual problems or the whole person?

“After decades of fragmenting medicine into specialties and subspecialties, it’s perhaps not surprising that a siloed system often fails those in need of whole-person care,” writes Druv Khular, MD, in a recent New York Times article. “I still sometimes wonder if I had let my patient’s mental illness overshadow his physical needs. Did I overlook some subtle cue?”

Khular isn’t concerned about missing something because he’s ambivalent. Rather, he was trained and works in a system that promotes specialization over generalization, even though he’s not an insect. (Perhaps Heinlein could have written something about a physician being able to “set a bone,” bind a wound, manage hypertension and navigate bipolar disorder.)

Among the challenges for physicians these days, Khular argues, are “therapeutic pessimism”—the tendency to think patients with mental illness can’t get better—and “diagnostic overshadowing” in which a patient’s physical problems are attributed to mental illness and not properly treated.

It’s not that specialization was or is necessarily a detrimental approach to healthcare. If I have a heart problem, I want my cardiologist to know as much about the heart as anyone on earth. It’s that the necessary approach is not always the optimal approach.

“Only 37 percent of doctors serve in primary care, yet 56 percent of the office visits are completed by that particular group of physicians,” writes Niran S. Al-Agba, a third-generation primary care physician. “In my grandfathers’ time, primary care physicians made up 70 to 80 percent of the physician workforce.”

Over the last few decades, as primary care doctors have become a smaller slice of the labor pool, the mortality ratio for people with schizophrenia versus the general population has steadily risen, from 1.8 in the 70s to 3.7 now. Yes, many other aspects of mental healthcare—a massive reduction in available psychiatric beds, for example—have changed in that time frame, but that still doesn’t let increased specialization and fewer primary care physicians off the hook.

The thing is, those with chronic mental illness don’t die of a mental illness. Their lives are shortened by the same diseases that end most lives—heart disease, diabetes, heart attack, cancer—exacerbated by a stronger tendency to abuse drugs, alcohol and tobacco.

“People with serious mental illness are often our toughest patients…” writes Lisa Rosenbaum, MD, in the New England Journal of Medicine (NEJM). “To meaningfully improve care for the mentally ill, we must recognize that, as Massachusetts General Hospital psychiatrist Oliver Freudenreich puts it, ‘Care integration is an attitude.’”

If so, it’s an attitude we’ve mostly failed to embrace.

“Once they find out you have a mental illness … it’s like the lights go out,” said Kenneth Reilly to his brother, Brendan Reilly, MD, author of a searing NEJM piece detailing his late brother’s experience. “Many doctors and nurses seethe about the profit-driven dis-integration of our health care market yet insist they can’t fix this mess themselves. Kenneth, no stranger to cognitive dissonance, said, ‘Well, if they can’t fix it, who the hell can?’”

The question hangs in the air and calls to mind all that we’ve learned of late about how behavioral health is the canary in the coal mind of our healthcare system. Opioid addiction ravages many parts of the country. Suicide rates have risen 25 percent nationwide since 1999. The mentally ill homeless aimlessly wander our cities.

And yet, despite heartbreaking stories and periods of hopelessness, the system is evolving in ways that better protect patients.

Khular points to the use of a transitional clinic by UT Health San Antonio that gives the mentally ill more support in getting back to life after discharge. While historically 7 percent of psychiatric patients transition back to the hospital within a month of being released, only 1 percent have returned after using the UT Health San Antonio program.

Last month the U.S. Senate passed legislation that offers incentives to behavioral health facilities for electronic health record (EHR) adoption and moves the entire healthcare industry one small step closer to giving clinicians complete patient records at the point of care.

Can the ability to see a history of both diabetes and bipolar disorder help overcome diagnostic overshadowing and improve treatment of the entire patient? Not by itself, no. But when paired with programs like the one at UT Health San Antonio, change is quite possible, if never easy.

It’s not just that emergency care for the mentally ill is the most expensive approach. It’s not just that specialization fails to recognize that each person is an integrated system. It’s that not caring for those literally incapable of caring for themselves undermines our humanity.

After all, we’re not insects, are we?

Irv Lichtenwald is president and CEO of  Medsphere Systems Corporation, the solution provider for the CareVue electronic health record.

Category: Behavioral Health

Opioid epidemic makes EHRs essential to public health

When public health is threatened by an outbreak of SARS or Zika or avian influenza, widely disseminated information becomes a crucial tool used to curtail the spread of disease.

But transmittable diseases are not the lone threats to public health. Other metaphorically pathogenic events—the current opioid epidemic, for example—are more effectively managed by making sure doctors have complete information when evaluating patients and, especially, writing prescriptions.

Even if you know what the opioid epidemic is doing to America, you may not be familiar with the devastating numbers. Here are a few.

  • Drug overdose is the leading cause of death for Americans under 50.
  • From 2015 to 2016, drug overdose deaths rose 19 percent. In Ohio, they increased by more than 25 percent.
  • Summit County (Akron), Ohio, experienced 312 drug deaths in 2016, a 46 percent increase over the previous year. The county had to request refrigerated trailers to store bodies.
  • In 2016, Fentanyl became all the rage, and in January and February of 2017, the area around Dayton, Ohio, saw 100 overdose deaths—99 from fentanyl or something similar.
  • It’s estimated that more than 2 million Americans are dependent on prescription opioids, but more than 95 million—almost 30 percent—used prescription painkillers last year.
  • About 6 percent of patients who take a prescription opioid for one day will be using them a year later; that number jumps to 35 percent for those who take the pills for more than 30 days.

Opioids now represent the single greatest drug overdose crisis in U.S. history and one of the most significant threats to American public health in the last century.

“In 2016 alone, drug overdoses likely killed more Americans in one year than the entire Vietnam War,” writes German Lopez in Vox. “In 2015, drug overdoses topped annual deaths from car crashes, gun violence, and even HIV/AIDS during that epidemic’s peak in 1995. In total, more than 140 people are estimated to die from drug overdoses every day in the US. About two-thirds of these drug overdose deaths are linked to opioids.”

Even those who think opioid deaths are social Darwinism at work can’t deny that the epidemic hamstrings the U.S. economy.

“About 1.8 million workers were out of the labor force for ‘other’ reasons at the beginning of this year, meaning they were not retired, in school, disabled or taking care of a loved one, according to Atlanta Federal Reserve data,” writes CNN Money reporter Patrick Gillespie. “Of those people, nearly half -- roughly 881,000 workers -- said in a survey that they had taken an opioid the day before, according to a study published last year by former White House economist Alan Krueger.”

In many places and in specific industries, employers simply cannot find enough sober citizens.

So, if those are the results of rampant opiate use, what are the solutions? Certainly, there isn’t just one, but all of them require coordinated and reliable data like that revealed in a 10-year study conducted by Geisinger Health System. After evaluating the electronic health record (EHR) data of more than 2,000 individuals admitted to the hospital for overdoses. Of that group, nearly 10 percent were dead within a year of hospitalization.

The study supports what may seem like common sense in some ways. Those who were single and unemployed were most likely to use and overdose. But if this is common sense, why didn’t it occur to those who were so often prescribing opiates? Why weren’t the extenuating circumstances—employment and marital status, as well as existing chronic illness—a concern? And why are women more likely to be addicts and die?

Perhaps because medicine is a data-driven science and the data on addiction and opiate abuse, combined with individual patient information, simply wasn’t there. While acute care facilities are now approaching 100 percent EHR adoption and the push for full interoperability continues, behavioral health hospitals languish at well below 50 percent, making interoperability irrelevant. Patients with myriad issues on top of chronic pain won’t sound alarm bells for doctors that lack a complete picture.

“First, we need to identify individuals who are at high risk for opioid use,” write Brian Sites, MD, and Matthew Davis, PhD. “Second, we need to develop and put in place health policies and practice guidelines … that aim to reduce physicians’ dependency on opioids for treating pain.

“Third, we need to carefully vet policies regarding financial reimbursement for outcomes such as patient satisfaction to anticipate any indirect effects on opioid prescribing. Finally, we need to quickly put in place regulatory policies to identify fraudulent prescribing practices and improve access to drug addiction treatment.”

Largely agreeing with Sites and Davis, German Lopez also suggests we “address the other problems that lead to addiction.”

These solutions will probably be beneficial if they’re supported by robust, interoperable information systems. Doctors and public officials need data to make informed individual patient decisions and to design impactful community programs. Where will that information come from, otherwise?

The rapid adoption of EHRs in acute care settings is the result of federal government incentives based on the idea that complete, coordinated patient information leads to better care and saves lives. As the opioid crisis demonstrates, that idea is just as relevant in behavioral health settings and is arguably more urgent.

Some of that urgency is felt in Congress. Senators Sheldon Whitehouse (D-RI) and Rob Portman (R-OH) last week introduced legislation that included incentives to digitize behavioral health records. A similar measure introduced by Lynn Jenkins (R-KS) and Doris Matsui (D-CA) is making its way through the House. Contact your local representative and encourage them to support the bills.

For the next couple of years, public health experts expect that opiate-related deaths will continue along the same path or perhaps increase in certain areas. Tragically, too many are already addicted, and the power and availability of Fentanyl can’t be easily combatted. But doctors and public health officials armed with a greater awareness and information about a specific patient can begin to stem the tide.

When Americans look back at this chapter in history, will we see the number of deaths and regret that we didn’t include behavioral health in efforts to provide doctors with complete patient information? It’s a trivial price to pay for hundreds of thousands of lives.

Irv Lichtenwald is president and CEO of Medsphere Systems Corporation, the solution provider for the OpenVista electronic health record.

Category: Behavioral Health

An American dilemma: Incarceration and the mentally ill

It’s generally common knowledge that the United States incarcerates a higher percentage of the population (716 per 100,000 people) than any other country on earth. With just 5 percent of the world’s total population, the U.S. still has 25 percent of the global prison population.

Especially in recent years, much ink has been spilt on how mandatory minimum sentencing and three-strikes laws have put thousands of non-violent, low-level drug offenders behind bars, creating prison overcrowding and decimating certain populations. Drug use, drug distribution and societal punishment for breaking associated laws is complicated and divisive, and I have no desire to argue the issue here.

I will, however, take a position on prison overcrowding caused by a different societal issue: incarceration of the mentally ill. Simply put, we’re doing a lousy job caring for the mentally ill, and we’re doing both ourselves and the afflicted a great disservice by not acting more responsibly.

The question is not whether we are warehousing the mentally ill in corrections facilities but how often this is happening.

At Chicago’s Cook County Jail, aka America’s largest mental health facility, estimates are that 1 in 3 inmates have some kind of mental illness. Marion County, Indiana, Sheriff John Layton, who recently broached the subject of incarcerating the mentally ill at a White House meeting, thinks perhaps 40 percent of inmates at his facility have some kind of mental illness. There are probably ten times more mentally ill people in jail than in actual mental health facilities, and the rate of mental illness in prisons and jails is three to six times higher than the national average.

Sure, many (Most? All?) mentally ill inmates did something illegal to wind up in a corrections facility. But would they have done the same thing had they been mentally sound or receiving appropriate care, and would American society choose incarceration over treatment if sufficient programs and facilities existed to create alternatives?

I think the answer to both questions is no. A confluence of factors going back to the 1960s—a deinstitutionalization movement that reduced state psychiatric beds from 550,000 to 40,000, the return of Vietnam War veterans, budget crises, to name just a few inputs—suggest the mentally ill are in jails because we don’t have anything else to do with them. State institutions were to be replaced by outpatient and community treatment centers, but that plan never reached fruition. If mental health resources ever were sufficient, they’re now a mere shadow of a once ambitious plan.

If jails were oriented both physically and organizationally to dealing with mentally ill prisoners, there might be some kind of argument for putting them there. Clearly, they are not, as both statistics and anecdotes demonstrate. Mentally ill inmates are almost three times as likely to be sexually assaulted, and there is strong tendency toward self-harm absent treatment and medication.

And then there are stories like this one (Warning: long read) of inmate abuse even within facilities focused on mental health treatment. 

When mentally ill offenders get the treatment they need, results improve dramatically. While the rate of recidivism for the incarcerated mentally ill is high (85 percent), it falls rapidly for those treated in forensic hospitals instead of regular corrections facilities.

While it may seem self-evident, I think it’s helpful to spell out exactly why we should be doing more—a lot more—to move the mentally ill out of correctional facilities and get them the help they need.

  • Incarceration is not a mental health treatment program. There is an extensive discussion to be had about the purpose of incarceration—punishment and/or rehabilitation—and whether it achieves stated goals. Again, I’m not here for that discussion. Without a doubt, incarceration does not improve the plight of someone with schizophrenia or bipolar disorder. In jails and prisons, many of the mentally ill are being punished for actions they had little or no control over. The rate of recidivism for the mentally ill who commit crimes is 85 percent. Without treatment, we’re just cynically ensuring the persistence of a prison population.
  • Technology available now enables us to improve this situation. At a minimum, permanent electronic health records (EHRs) make it easier to rapidly see a patient’s history and use that information to assess. Interoperable systems and correction-specific solutions enable better care. Currently, these kinds of fluid communication between facilities are rare. Mental health professionals who work inside the corrections system also see a role for technology in providing inmates with more complete information on the judicial process, evaluating inmates for the potential of mental illness and enabling research on confined populations.
  • We have an obligation to fix this. There are extenuating circumstances in any inmate’s life, but the inability to effectively manage acceptable and unacceptable behavior because you’re mentally incapacitated seems exceptionally extenuating. If American society has basically been letting the mentally ill down for decades, it’s our responsibility now to right a historic wrong.

Of course, the crisis of incarcerating the mentally ill has not gone unnoticed. Many public health professionals have and continue to look at ways to fix the problem, including diversion programs that identify the mentally ill and set them on a treatment path. Such efforts are just the initial stages of what must be a more concerted effort, however, as even current research suggests diversion treatment programs must be augmented by other ways to prevent criminal behavior.

One bullet above just touches on the potential technology offers to either divert the mentally ill away from the corrections system or improve their care within it, but it isn’t enough by itself. We have to make some difficult budgeting decisions, and we must reorient our priorities. If the mentally ill are being housed in jails for lack of options, we clearly have to create options. It’s not just that a more thoughtful approach yields better results. Perhaps more importantly, it helps define who we are as a society when that definition seems elusive and positive examples can make a tremendous impact.

Irv Lichtenwald is president and CEO of Medsphere Systems Corporation, the solution provider for the OpenVista electronic health record.

Category: Behavioral Health

Parity Not Apparent: Mental illness still not receiving equal attention

Getting legislation through Congress—often a monumental battle, as demonstrated by recent efforts to pass the American Health Care Act—is one thing. But implementing new laws may be a greater challenge simply because they require so much sustained energy and attention.

Take mental health parity laws, for example.

Congress passed the Mental Health Parity Act (MHPA) championed by Sens. Paul Wellstone (D-MN) and Pete Domenici (R-NM) in 1996. The law prohibits employee-sponsored group health plans from charging more in a year or over a lifetime for mental health care than for medical or surgical care. The MHPA doesn’t make health plans cover mental health, it just says they can’t charge more if it is included.

In 2008 Congress passed the Mental Health Parity and Addiction Equity Act (MHPAEA) to cover the gaps in MHPA. A 2015 proposed rule related to MHPAEA requires Medicaid and Children’s Health Insurance Program (CHIP) managed-care plans to cover mental health and addiction treatment at the same level as medical and surgical care.

If you’re not keeping track, that’s almost 20 years between passing the initial MHPA legislation and a proposed rule suggesting a failure to treat mental illness and addiction damages lives and hampers the economy.

The troubling element of the Mental Health Parity saga is not that Congress and federal agencies have to keep going back and adding more layers. It’s common to revisit legislation and tweak it a bit. Rather, the disconcerting truth is that the legislation has not achieved its goal of actually treating the addicted and mentally ill. Yes, volumes of legislation have been unsuccessful, but this is a challenge we probably can’t afford to shrink from if we hope to truly provide holistic treatment and lessen the impact of healthcare on the economy.

The mental health diagnostics challenge

Closing a wound or treating cancer is pretty straightforward in terms of diagnosis. We can know that the problem exists. With mental illness or addiction, there is no hard evidence besides the patient’s behavior, which society can still attribute to personal flaws, bad choices, poor parenting, etc.

Writing in the online magazine Slate, psychotherapist Darcy Lockman describes being contacted by a patient’s insurance company about the projected duration of his treatment. When told that therapy could constructively last five years, the insurance company representative says, “he is certainly welcome to do that, but we are not going to pay for it.”

The response is understandable. Insurance is a business, and businesses must minimize costs. In the case of insurance, they do so by paying only for what is a “medical necessity.” And, of course, what seems absolutely necessary to a therapist appears much less so to the insurance company.

Lockman is not without perspective on this disconnect.

“One could certainly make a case for health insurance not covering psychotherapy at all,” she writes.  “Why should an insurer be obligated to pay for a treatment that relieves emotional suffering? Is that not a luxury, like massage, that could come out of pocket?”

What’s needed is an agreed-upon definition of equivalence of services between mental health/addiction benefits and medical/surgical benefits. Currently, there is no equivalency between an extensive addiction treatment program and anything in internal medicine. “Full parity demands that standards of evidence be applied consistently across mental health/substance use and medical/surgical treatments,” writes a team of policy consultants in a Health Affairs journal “Health Policy Brief.”

Legislation without representation

One great frustration for mental health parity advocates is that there is frequently no one to provide necessary treatment when a patient is diagnosed with some kind of behavioral health ailment. As he describes in a Health Affairs article, Peter Cunningham found that two-thirds of primary care physicians were unable to find a mental health professional to care for a patient after diagnosis.

In immediately dire situations, finding a facility to house the mentally ill is equally challenging, if not more so. In a series on mental illness in America by USA Today, Robert Glover, executive director of the National Association of State Mental Health Program Directors, says that states cut $5 billion from mental health services and eliminated at least 4500 public psychiatric beds between 2009 and 2012. For the most part, those numbers have no recovered to pre-recession levels.

According to a 2012 National Survey on Drug Use and Health by the Substance Abuse and Mental Health Services Administration (SAMHSA), almost 40 percent of adults with severe mental illnesses such as schizophrenia and bipolar disorder received no treatment in the previous year; among those with any kind of mental illness, 60 percent went untreated.

The cracks are very wide

The American healthcare system is as fragmented as an antique vase dropped from the third floor, and untreated mental illness is one price we pay for that fragmentation.

The solution, according to Health Affairs, must include these improvements:

  • Integrate and coordinate mental health and substance use care with medical care, even when using separate benefits administrators
  • Coordinate care among different health professionals and services
  • Identify co-occurring physical disorders among the mentally ill, and correctly diagnose medical conditions that may place people at risk for mental disorders

In other words, coordinate, coordinate, coordinate … and then find time to coordinate some more.

And that coordination must reach across state lines and levels of government. Estimates of the number of homeless nationwide range from 610,000 by the U.S. Department of Housing and Urban Development (HUD) to a staggering 3.5 million by other homeless advocacy groups. According to HUD, roughly one-fifth suffer from a severe mental illness. Among the homeless, the emergency department is usually the only option for medical care, which means we are using the most expensive form of medical care to treat people with no insurance and negligible ability to care for themselves.

Creating an actual system

The answers for America’s mental health challenges are neither simple nor immediate. In-depth studies showing dramatic cost savings by providing the mentally ill homeless with housing and support have prompted some states to construct apartment buildings and provide counseling. That’s one solution.

But housing and counseling are not panaceas because America does not have a healthcare system. There can’t be a single solution for a disjointed, patchwork approach to fundamental human need. Healthcare is a universal. We all have to have it, some more often than others.  

Mental Health Parity legislation is, characteristically, regulation of the insurance industry, not healthcare. Like the Affordable Care Act, which survives for now, it tells insurance companies what they can and cannot do without making associated changes in care provision.

America needs to integrate its healthcare and health insurance industries so that mandating something here makes it possible over there. Information systems must be integrated so ED docs know a patient is schizophrenic when he walks in with a broken hand and can refer him for treatment and perhaps an extended stay in a mental health facility. Of course, there needs to be a local facility to receive that referral.

And, at the ground level, families dealing with mental illness need support so members don’t end up on the streets, wandering and lost.  Yes, parity legislation is well-intentioned and necessary, but it requires an actual system to support it. We still have a long way to go. 

Click here to learn more about how Medsphere supports behavioral health care.

Irv Lichtenwald is president and CEO of Medsphere Systems Corporation, the solution provider for the OpenVista electronic health record.

Category: Behavioral Health

Can effective healthcare IT reduce hospital costs?

The focus of federal efforts to incentivize healthcare IT adoption has primarily been on electronic health records (EHRs), which are oriented around hospitals and physician offices. Moving forward, EHRs will remain the anchor technology as data from other devices and applications flows in and becomes both available and comparable.

It’s become readily apparent that healthcare IT is much broader than EHRs alone. Increasingly, healthcare IT is a web of interconnected devices and applications that can feed data to the EHR. So, instead of focusing intently on how healthcare IT can alter inpatient safety and quality, we’re better off looking at technology as all the tools patients and doctors can use to maintain and improve health.

Why might this shift in focus be important? One obvious reason is that hospital and emergency care are expensive. The average cost for a single inpatient day in the United States is more than $2,200. The average cost of an ER visit is about the same—$2,168—without being admitted.

The better reason is that hospital visits often mean something has gone wrong. Sure, some hospital stays or visits are required because life is messy and people get in accidents. But others are the product of preventable scenarios. Instead of focusing on crisis-scenario work, perhaps there is wisdom in focusing on the more mundane tasks technology can perform to keep people out of the hospital.

How, specifically, can we use IT to make patients better shepherds of their own care?

  • Identify at-risk patients. Age, ethnicity, health history, gender, geographic location and other population health data give healthcare professionals a pretty good idea of who will get sick. Obviously, primary care providers also have a significant role to play when it comes to identifying potential health problems and engaging the patient in a plan to avoid them.

    When it comes to at-risk patients, technology is essential but not sufficient on its own. A better approach might be a care management scenario that combines big data analytics, the collaboration of multiple providers,  and human insight. 

  • Monitor patients’ vitals and welfare. For a while now, wearable devices have given healthcare the ability to track patients outside of the hospital and clinic. That tracked data can be relayed wirelessly back to the EHR and is available to physicians when they check patient status.

    Remote patient evaluation is also available more directly via telehealth. Through remote consultations and evaluations, a physician can usually determine whether a patient should come to the hospital or is fine at home. As is often mentioned, telehealth offers great potential in terms of treating patients in remote areas where hospitals and specialists are few. 

  • Remind patients of appointments. No-show rates for patients vary wildly—anywhere from 5 percent to 55 percent—with similarly varying impact on patient health. Sometimes a patient misses a cardiac stress test and shortly thereafter suffers a heart attack. Other times a routine checkup is missed with no physical fallout.

    The point is that patient portals and regular communication provide services both banal—the patient is simply reminded that they have an appointment—and potentially essential in the case of a cardiac diagnostic. Regular communication in advance of a test is an opportunity to provide patients with reassurance and more information on the potential benefits of attending the appointment.

  • Empower them to manage their own care. Especially regarding behavioral health, technology enables patients to learn self-management techniques that improve coping skills and ideally prevent incidents requiring hospitalization. Support for self-directed or self-managed care comes from Health and Human Services, the Centers for Disease Control and Stanford University Medical School, among others. For self-directed care objectives, mobile phone applications can remind people to take medications, track heart rates, help with stress and anxiety, and improve thinking skills, to name but a few benefits.

    It’s limiting, however, to think of self-managed care as essentially behavior health-related. All patients can benefit from technological assistance with taking medications regularly, improving dietary choices, monitoring blood pressure and getting some exercise. All of these daily activities could help keep someone out of the hospital.

  • Provide educational information. The internet is a jungle of information, some of it benign and some much less so. Hospitals and practices can direct patients toward reliable sources and can provide their own via PDF documentation and the patient portal. In fact, the internet is both an animating and potentially complicating factor in patient care, requiring providers, perhaps especially nurses, to evaluate information patients bring to appointments and correct as necessary. 

Of course, the ultimate focus in reducing hospital admissions is on patient health and welfare, but the corollary is runaway health costs in the United States and the need to wrestle them into submission. Once hospital admissions take place, things get expensive, making just about all efforts leading up to the hospital visit more attractive and cost effective.

The federal government (CMS, HHS) has made reducing hospital readmissions a primary objective and a criterion impacting hospital reimbursements. But there can’t be a readmission if admission is avoided in the first place. Moving forward, integrated, aware health systems will focus as much on preventing hospital visits as they will on making sure patients don’t come right back.

D'Arcy Gue is Director of Industry Relations for Medsphere Systems Corporation. 

5 ways technology makes behavioral health care better

Are you old enough to remember the pre-concert security searches for recording devices that were once part of every live music experience? Yes, musicians once had some semblance of control over bootleg audio and video.

But the proliferation of tiny hand-held computers that happen to also make phone calls ended all that. Now, tossing music-lovers who pull out a phone to record would empty entire arenas save a few luddites with flip phones and mullets.

Sometimes silently, other times with great fanfare, technology has wormed its way into almost every aspect of life. Much has been written about the use of electronic health records in healthcare, for example, but EHRs are just one example.

In behavioral health, EHR adoption lacks financial incentives so the rate of adoption has lagged that of acute care. And still technology creeps into the way we provide behavioral health care, in many ways transforming and often improving treatment, compliance and reporting.

One could argue that the potential for positive disruption is greater in behavioral health than in any other subset of medicine and healthcare. So how, exactly, is technology upsetting the behavioral health apple cart in beneficial ways?

  1. Improving correlation of health information: There is a strong likelihood that a patient with bipolar disorder or a similar affliction is also self-medicating with drugs and alcohol. Sure, a caregiver somewhere along the way might notice the physical signs of abuse, but they also might not. A comprehensive EHR that includes patient data from coordinated providers would provide that information, just as it would when the bipolar patient shows up at the ER with a broken arm.

    According to the National Bureau of Economic Research, Americans with a current mental illness account for 38 percent of all alcohol, 44 percent of all cocaine and 40 percent of all cigarettes consumed in the country. Those who have ever had a mental illness consume 69 percent of all alcohol, 84 percent of cocaine and 68 percent of cigarettes. Therapists might sometimes have the luxury of just treating a mental illness, but around half the time they will also be working with an addiction problem and must aware of both.

  2. Making care available outside urban areas: The numbers suggest mental health counselors are jockeying for clients in urban areas and scrambling to meet overwhelming demand in rural sections of the country. Rates of alcoholism, opiate abuse and generally risky behavior are higher outside of major cities, creating a burgeoning healthcare crisis in the parts of the economy oriented around agriculture and energy.

    With few promising alternatives, much of the push to resolve America’s rural health conundrum is now focused on telehealth, and with good reason. Telehealth has proven effective thus far in treating depression and PTSD. According to a 2012 Institute of Medicine report, telehealth also increases volume, improves care and cuts costs by keeping patients out of the ER and reducing readmissions. 

  3. Boosting the bottom line: A comprehensive EHR combined with robust revenue cycle tools and services ensures that behavioral health care providers are compensated more reliably for the care they provide.

    “An EMR is an investment because it provides long-term benefits and may be an important tool for reducing the cost of expenses,” writes Carol Turso in Behavioral Healthcare.

    Turso uses the example of a social services organization that over three years after implementing an EHR reduced bad debt by 93 percent, lowered outstanding accounts receivable of more than 151 days from 24 to 9 percent, and trimmed the time staff spent per week entering remittances and payments from 40 hours to 10 minutes. In every instance, these EHR benefits improve the organization’s bottom line. Even if they don’t technically create new revenue, they are still financially relevant.

  4. Enabling self-directed care: At its core, self-directed care is empowerment focused on dealing with pain and frustration, getting regular exercise, eating well and communicating with counselors and family. Self-directed care engages the patient more fully in the care process, even in some instances allowing patients input on how and where to spend the money applied to their treatment.

    In recent years, the self-directed care model has gained more currency in the provision of behavioral health care. Support for self-directed or self-managed care comes from Health and Human Services, the Centers for Disease Control and Stanford University Medical School, among others. For self-directed care objectives, technology, especially mobile phones, offers support and assistance. 

  5. Giving kids something to do: Do mobile devices keep kids off drugs? The jury is still out, but it’s one explanation for a steady downward trend over the last decade of teenagers experimenting with drugs and alcohol. Correlation, of course, is not causation, which is why the National Institute on Drug Abuse plans to make this the subject of a study over the next several months.

    While many teenagers seem as addicted to mobile phones as they might be to marijuana, parents will probably rest easier knowing the former might be preventing the latter.

The proliferation of technology, especially in healthcare, is something that must be monitored over time and re-evaluated regularly. As some healthcare economists have pointed out, technology drives up healthcare costs more than any other factor.

But behavioral health, specifically, will never have to invest in massively expensive tools like MRI machines, creating an opportunity for the grassroots use of relatively affordable handheld and desktop technology that over time can affect measurable change in the lives of patients.  

D'Arcy Gue is Director of Industry Relations for Medsphere Systems Corporation. 

When illnesses collude: How comorbidity threatens American healthcare

Comorbidity is not a word heard every day—not even in healthcare, where it applies. But researchers and physicians, assisted by IT-derived diagnostic data, have come to understand that comorbidity is essential to understanding and managing population health, especially among vulnerable populations challenged by mental illness and addiction.

A patient with comorbidity has at least two chronic diseases at the same time that interact in such a way as to worsen the impact of each illness on the individual. Imagine irritable bowel syndrome or Crone’s and diabetes working in tandem, for example, and it’s not hard to see how comorbidity becomes a tag-team bludgeon.

Among the total population of the United States, 25 percent have multiple chronic conditions, according to the Centers for Disease Control and Prevention (CDC). Of course, those chronic conditions are not limited to the physical. Once we include mental illness and substance abuse in the definition of comorbidity, rates rise dramatically and are often more debilitating.

There is simply no denying that even the most common mental illness creates the risk of comorbidity with drug and alcohol abuse. According to the National Bureau of Economic Research, Americans with a current mental illness account for 38 percent of all alcohol, 44 percent of all cocaine and 40 percent of all cigarettes consumed in the country. Those who have ever had a mental illness consume 69 percent of all alcohol, 84 percent of cocaine and 68 percent of cigarettes.

In this environment, doctors and the healthcare system are not tasked with just treating a physical illness or three. They also have to treat a physical challenge that may have been neglected due to mental illness made worse by substance abuse. Or maybe they’re trying to wean a patient off heroin used to deal with chronic pain after the OxyContin subscriptions ran out.

It’s this complex self-medication dance that regularly doubles back on itself and dramatically ratchets up costs in terms of both healthcare dollars and lives. Opiate-related deaths just recently surpassed those from gun violence, and healthcare costs rose 3.4 percent last August, the highest one-month rise since 1984.

“On average individuals with chronic medical conditions incur health care costs two to three times higher when they have a comorbid substance use disorder compared with individuals without this comorbidity,” wrote Surgeon General Vivek Murthy in his recent report on addiction in America.

No, mental illness does not always lead to substance abuse and an often irreversible downward spiral. But addiction always makes both physical and mental illnesses far worse, even if we cannot determine causality or directionality.

A survey by the National Institute on Alcohol Abuse and Alcoholism, for example, identified comorbidity in a majority of respondents. A separate study by the NIAAA found that 56 percent of subjects with bipolar disorder also practiced some form of alcohol abuse and were more likely to have medical comorbidities like lung and breathing issues because smoking is so common.

How can we deal with mental illness to try and avoid substance abuse and medical comorbidity?

  • Catch it early. “… research indicates that 90 percent of people who develop a substance use disorder started their use before age eighteen,” writes Alexa Eggleston of the Conrad Hilton Foundation in a recent Health Affairs blog post. Eggleston speaks of substance abuse in general, but the risks are greater in the teenage years, when most mental disturbances manifest, making increased awareness even more necessary.
  • Initiate treatment. Addressing a mental issue is more straightforward before comorbidity becomes a factor. If mental illness and substance abuse comorbidity happens, treatment should focus on both issues at once, according to the National Institute on Drug Abuse.
  • Break down silos. The unfortunate tendency in healthcare going back decades has been to silo information and care. Treatment has tended to focus on independent specialists treating separate aspects of the patient condition without fully addressing how they impact one another. That must end. The placebo effect, for example, shows us that the brain and the body are not separate and that treating them as unrelated makes as much sense as changing the oil on a car with four flat tires.

To be sure, changes to the way we provide care—paying for value, Patient Centered Medical Homes, ACOs, HIEs, etc.—have gained great momentum that should continue. As mandated by the recently passed 21st Century Cures Act, interoperability among healthcare IT systems must become a reality so ER docs can see when a patient is bipolar and family practitioners know immediately that their new patient is on anti-psychotics.

Annually, the United States spends $35 billion from both public and private payors to treat substance misuse, but that’s a small fraction of the amount addiction extracts from American society in terms of services for the homeless, work absenteeism, broken families and other types of fallout. In total, substance abuse is estimated to cost the United States more than $400 billion each year, an amount that is 2/3 that of the Pentagon budget.

We are currently in the midst of one of the worst drug-addiction epidemics the nation has experienced. No, integration of patient record systems and patient care protocols will not prevent the destructive chain of events that leads to substance abuse, but becoming more alert to the frequency and severity of comorbidities may enable us to see warning signs sooner, share information and work more interactively with other caregivers, and more effectively improve patients’ overall health and quality of life. And this multi-pronged approach to quality of care will very likely minimize the costs to society in the process.

Irv Lichtenwald is president and CEO of Medsphere Systems Corporation, the solution provider for the OpenVista electronic health record.

Cures Act: A bag of holiday gifts for healthcare

On Tuesday, President Obama signed the 21st Century Cures Act, codifying a broad and far-reaching effort to achieve medical breakthroughs in Alzheimer’s and other debilitating afflictions through improved, streamlined, well-funded research.

The Cures Act gives particular attention to cancer and Vice President Joe Biden’s Cancer Moonshot initiative, which hopes to transform research and make certain varieties of the illness either manageable or history.

“God willing, this bill will literally, not figuratively, literally save lives,” Biden said at the signing ceremony. “But most of all what it does … is gives millions of Americans hope. There’s probably not a one of you in this audience or anyone listening to this who hasn’t had a family member or friend or someone touched by cancer.”

The Cancer Moonshot illustrates well how most of the Cures Act focuses on research and additional funding for the National Institutes of Health and similar agencies. But it also focuses on bettering the current provision of healthcare by improving behavioral health care and healthcare IT.

Viewed from a high level, Congress is focused on stemming the tide of mental illness and opioid addiction in America, as well as making sure healthcare information flows freely and safely among providers to improve patient care. Read on for highlights.

Mental Illness and Addiction

Via the specific proposals below, the Cures Act endeavors to better fund mental health care and opiate addiction, improve leadership and planning, ramp up research, enforce parity and improve preparedness among police and in the legal system.

  • Over the next two years, the Cures Act provides $1 billion in state grants for opioid abuse prevention and treatment. Specific parts of the proposal include prescription drug monitoring, healthcare provider training and better access to treatment programs. Indeed, block grants to state agencies are clearly aimed at helping individuals break out of the addiction cycle that so often includes homelessness and limited family support.
  • Grants will also go to higher education and professional training programs to put more mental health professionals in the field.
  • The Act also creates new positions—an assistant secretary for mental health and substance use, and a chief medical officer—in the Substance Abuse and Mental Health Services Administration (SAMHSA).
  • Apparently not a sanctioned SAMHSA component previously, the Center for Behavioral Health Statistics and Quality is now codified in the Cures Act, as is the requirement that SAMHSA create a strategic plan every four years to identify priorities and strengthen the mental health workforce.
  • Mostly through reauthorizations, the Cures Act provides funds for mental health programs that pay specific attention to some vulnerable populations: college students, women and children.
  • Mental health parity, already a law but sometimes inadequately enforced, will become more of a focus for HHS, which is being asked to draw up a federal and state compliance action plan.

Healthcare IT

While there are efforts in the Cures Act to improve the functionality of EHRs and access to records for patients, the real focus is on improving the flow of information.

  • Apparently fed up with allegations of information blocking, Congress included in the Cures Act $15 million in funding for improved interoperability and less information blocking. Some of the money will support a voluntary framework for information exchange and some will go to HHS to investigate claims of information blocking and punish the blockers to the tune of $1 million per violation. The Government Accounting Office is also required to evaluate patient access to personal health information and why it might sometimes be difficult to get.
  • Congress is also requiring HHS to change the terms of Meaningful Use to include interoperability. Moving forward, healthcare IT vendors must develop application programming interfaces (APIs) and apply real-world tests of interoperability to EHR systems.
  • If the Cures Act has a measurable impact, EHRs will become more patient-centric. Incorporated language speaks to making patient records more simple and easier to use, and continuing to grow Health Information Exchanges (HIEs) to expand patient access to care.
  • A new HIT Advisory Committee will make recommendations to the national coordinator on a host of healthcare IT concerns. Of particular interest will be the segmentation of data so that only select parts of a patient record can be shared and sensitive data related to mental illness and drug addiction can be closely controlled.
  • The Advisory Committee will also have the authority to make recommendations on population health, healthcare for children, telemedicine and other potential improvements to healthcare available through IT.

At nearly 1000 pages, the Cures Act obviously includes much more than the greatest hits included here. The curious might visit this highlights document and find specific objectives that perhaps are more relevant and important.

As with all federal legislation, efficacy is measured by impact over time, not number of pages or total appropriations. With the Cures Act, we can hope that the grant money will make a significant difference at the local level and that patient health information will flow more freely between coordinated providers. A cancer breakthrough wouldn’t hurt, either.

D'Arcy Gue is Director of Industry Relations for Medsphere Systems Corporation. 

Cures Act is a strong mental health vaccination. Booster shots required.

Remember that the two things you don’t want to watch being made are sausage and law. Then recall that while the process for both may be unappealing and seem incongruous, the product is not always so.  

Take the 21st Century Cures Act, for example, which is a lengthy (996 pages) piece of legislation (summary here) that focuses primarily on health-related scientific research and medical devices. It also broadly outlines the terms for an upcoming drawdown of America’s strategic petroleum reserve, which may look like a rider but is actually a way to pay for the bill.

The sale of crude will also help fund mental health and addiction treatment, about which the Cures Act has something to say thanks to language appropriated from the Helping Families in Mental Health Crisis Reform Act. That bill passed the House earlier this year but has languished in the Senate since.

It’s encouraging to see Congress address mental illness and addiction, and the Cures Act works to address many of the issues that plague American mental health care and bleed into acute care as well.

Read on for more on what the Cures Act does and doesn’t do to improve mental health care.

What does the Cures Act do for mental health care?

  1. Provide More Money: Over two years, the Cures Act provides $1 billion in block grants to the states for opioid abuse prevention and treatment through prescription drug monitoring, prevention programs and healthcare worker training. It also provides or reauthorizes a host of other targeted grants focused on specific goals and populations, including treatment of students on college campuses.

  2. Create New Leadership and Planning: The bill establishes a new assistant secretary for mental health and substance use to head the Substance Abuse and Mental Health Services Administration (SAMHSA), as well as a chief medical officer within SAMHSA to help with program creation and development. 

  3. Promote Cutting Edge Research: Moving forward, a new National Mental Health and Substance Use Policy Laboratory (NMHSUPL … whew!) would be responsible for focusing evidence-based, scientifically oriented treatment on mental illness and addiction. The laboratory would also identify and respond to regionally specific mental health and addiction challenges.

  4. Push Parity: The Cures Act puts the onus for verification of compliance with parity legislation—the requirement that insurance policies cover mental and physical health equally—on Health and Human Services (HHS), Labor and Treasury. Down the road, the Government Accounting Office and CMS will evaluate whether or not parity compliance is happening. 

  5. Support Mental Health Training in the Legal System: Approved use of existing funds would empower law enforcement to create mental health crisis intervention teams and pay for targeted training. Additionally, the Cures Act requires the attorney general and courts to create a drug and mental health court pilot program.

What does the Cures Act NOT do for mental health care?

  1. Enable Integration with Acute Care: Despite there being funds for many programs, none were appropriated for expanding use of EHRs in mental health facilities. It seems like an omission, especially given the success of EHR adoption in acute care hospitals and the interoperability requirements included in other sections of the act. Interoperability is great and overdue, but it should be spread across the continuum of care to maximize impact.

  2. Add Beds: This isn’t a completely fair criticism, given that there is grant funding to states in the Cures Act that perhaps could be used for new facilities with more beds. But there isn’t a mandate with supporting funds to make up for the 4,500 public psychiatric beds that were lost between 2009 and 2012 and pretty much remain so. Indeed, when the need seems to be increasing, the number of psychiatric beds in the U.S. remains at record lows, contributing greatly to homelessness in urban areas and misuse of emergency department resources.

  3. Expand the Pool of Therapists: Outside of urban areas, professional therapists are hard to find and referring physicians have few options. Federal programs already exist that give teachers and doctors financial incentives (loan forgiveness) to work in areas where their skills are most needed. It seems like doing the same for therapists of various stripes—assuming such programs don’t already exist—is warranted. States could conceivably use grant funds to accomplish this goal, but federal law could offer more support. 

  4. Appropriate Enough Money: Looking at the number alone, $1 billion looks like a lot of money. As a sliver of the federal budget, and given the mental health and addiction challenges plaguing states, it may prove inadequate without viewing it as a down payment on a larger commitment. According to Robert Glover, executive director of the National Association of State Mental Health Program Directors, from 2009 to 2012 the states cut roughly $5 billion in mental health services, so 20 percent of that total at best may be restored.

Given what we know in the 21st century about mental illness—how common it is and how much human potential and productivity it drains from society—it’s not hard to envision behavioral health and addiction issues as some of the nation’s most daunting challenges.

But the 21st Century Cures Act, while focused on improving healthcare through better, more rapid research, perhaps tries too hard to be all things to all people. It won’t be. As with most legislation, the Cures Act will hopefully establish a foundation on which additional legislation can build. Subsequent legislative efforts should focus on expanding the pool of beds and therapists, and on integrating with acute care.

Let’s make sure those changes happen before there is a 22nd Century Cures Act.

Irv Lichtenwald is president and CEO of Medsphere Systems Corporation, the solution provider for the OpenVista electronic health record.

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