Friday, February 27, 2009

Sitting at a Meeting: Wraparound Nationwide (5:10 PM-PST Update)

I am off to California now, at the AAP's Future of Pediatrics meeting, where there is a lot of stuff about mental health reform being discussed;  I will be discussing some of the things that I learn over the next few days.  I just sat down to a session  and was speaking with Shelley Joyce, the Project Manager for Family to Family Oregon, which sounds like the sort of folks in Oregon who are doing the sort of work in which we are engaged in Massachusetts. We were talking about the challenges of recruiting and training a Peer-to-Peer mentors, one of the challenges that awaits our CSAs once this all comes to fruition.  She spoke well of their experience and told me that they have some resources available on their website that we might find useful.  She is right;  lots of stuff on wraparound and a little on Peer-to-Peer mentoring.  I'll post more useful things that I find as I go along.
So it is a little later in the day, and I've gotten some more interesting thoughts:
1) Obesity and Latinas- I heard a talk about a Healthy Tomorrows project that was trying to create an obesity prevention program in New Britain CT.  So when they went to start the program, they very appropriately asked the girls (largely Latino) what they thought about this-  the girls hated it.  They wanted nothing to do with obesity prevention-  they saw overwieght as not a problem and they weren't going to show up to a program rigged to make fix a problem that they didn't see it.  After some focus, though, it became clear that they would show up if it was packaged differently, in a positive way-  "Looking Good, Feeling Good" or something like that.  Maybe that's how we need to look at mental illness;  "Getting a Grip on Life" or some other upbeat sort of title for the work that we are doing to improve mental health.
2) Teaching compassion is important, but difficult and hard to measure-We heard from two programs teaching about "others", one in the context of refugee health, the other from a border clinic.  They cite one of the major benefits of the programs was cited as the development of "compassion" which often doesn't show up in standardized test score.  In this new system that we are designing, are we going to be able to measure the compassion that is shown by the system?
3)  Massachusetts mental health issues are national issues:  In Iowa, there are something like 70 child psychiatrists and equally few psychologists-  doctors do much of the mental health care.  In Ohio, payment issues are driving people away from practices that work with Medicaid.  In Washington State, a newly minted pediatrician was surprised at how much mental health care there was in primary care practice, and how little training he had in this area.  Our work will be of national importance.
More later.

Rosie D and the Great Recession: A Modified Court Order

This just came down from the Court in Springfield.  I confess to enjoying reading the jargon of the Court;  I know that they don't wear wigs anymore, but all of those episodes of Masterpiece Theatre just give me an image of a judge that is probably much more severe than was seen in real life.  Thanks, Judge Posner:

"The court is sensitive to the difficult decisions that these economic times force onto the Commonwealth and is willing to respond with some degree of flexibility. On the other hand, these children have already waited far too long
for the services they are legally entitled to under the Medicaid statute. The modification adopted by the court represents the fairest and most sensible balance achievable in this situation.
Based on the foregoing, the court hereby ALLOWS Defendants’ Motion to Modify Judgment (Dkt. No. 431), to the extent that In-Home Behavioral Services and Therapeutic Mentoring Services may commence by October 1, 2009, In-Home Therapy Services may commence by November 1, 2009, and Crisis Stabilization Services may commence by December 1, 2009. In all other respects, the original Remedial Order of February 22, 2007 will remain as issued.
It is So Ordered."

Case 3:01-cv-30199-MAP Document 443 Filed 02/27/2009

Wednesday, February 25, 2009

From the Children's Mental Health Campaign

Save The Date: CMHC Meeting
Tuesday, March 17 from 9:30-11 AM
Please join us for the next Children's Mental Health Campaign supporters meeting on Tuesday, March 17 from 9:30-11 AM in the 9th floor conference room at 30 Winter Street.  Even with the passage and enactment of Chapter 321 last session, the work of the Campaign has not slowed down.  At this meeting, we will discuss the implementation of the new law, legislative and budget strategy for the next several months, and other issues to monitor related to children's mental health.  Also at this meeting, Susan Stelk, director of the EOHHS Integrated Comprehensive Resources in Schools project, will present on the Department's work on mental health resources for children in school settings 

Your involvement in these meetings is important.  We have assembled a strong group of individuals and organizations, and our collective knowledge and experience will be key to making lasting systems reforms.
Please join us on March 17. 

FY 2010 Budget and Children's Mental Health

These remain difficult economic times in Massachusetts and these difficulties were reflected in Governor Patrick's FY 2010 budget proposal.  Of particular concern for children's mental health is a proposed $3 million cut in the Child and Adolescent Mental Health Services line item (5042-5000) According to analysis by the Mental Health and Substance Abuse Corporations of Massachusetts, this cut represents the annualization of the 9C cuts that were made to the line item last year.  The Department of Mental Health does not expect to make additional cuts in community services for this population.   Especially in light of the current financial crisis, the Children's Mental Health Campaign will continue to advocate for adequate funding for children with mental health needs.  Regardless of the budget situation, these young people continue to have needs that must be addressed. 

CMHC State House Operations
As you know, there have been many changes at the State House in the past several weeks.  In addition to a new Speaker, Representative Liz Malia and Senator Jen Flanagan have been tapped to lead the Mental Health and Substance Abuse Committee. 
This session, the Campaign is supporting legislation sponsored by Representative Ruth Balser and Senator Steven Tolman that would establish reimbusement under private insurance for collateral contacts by mental health clinicians.  (House Docket No. 1439 / Senate Docket No. 905)
Click here for an updated fact sheet on the Collateral Contacts legislation. 
Thanks to the work of the Campaign, we managed to secure 50 cosponsors on this bill. 
Click here to see who signed on. 
If you have any questions, please contact Matt Noyes, Children's Health Coordinator at Health Care For All. 

Tuesday, February 24, 2009

So, where are we now?

As I wrote on Friday, it has been interesting for me over the past few days to reflect on the strange, winding path along which children's mental health services has meandered over the past few years.   There is a wonderful perspective piece in this month's Academic Pediatrics (full disclosure-  I am currently chair of the Journal Committee at the Academic Pediatric Association) entitled "Evolution of Child Mental Health Services in Primary Care", which you can access through your library.  The authors looked at how the literature on the provision of mental health services has changed since the days of the "new morbidity" in the 1970s;  proposals have moved from improved communication and better screening to the development of clinical protocols and co-located/integrated services in the context of the medical home.  They present a pretty optimistic view of the future-  it is worth a look.

Saturday, February 21, 2009

More on the CANS from the CBHI

Got this via e-mail from the CBHI:
Introduction for New Users of the CBHI application on the Virtual Gateway Conference Call
Are you a behavioral health clinician, clinical director or access administrator who is new to entering CANS data into the CBHI application on the Virtual Gateway? Have you been using the CBHI application but feel that you could use a "refresher" session or "help with the basics"? If so, you are invited to join a Conference Call for New CANS Users on Friday, March 6, 2009 from 12:00 p.m. to 1:00 p.m. Jack Simons, Assistant Director of the Children's Behavioral Health Initiative, along with staff from the CANS Training Center and the Virtual Gateway, will discuss using the CANS Application on the Virtual Gateway and answer your questions. We hope you will join us.

Introduction to CANS Conference Call Information
Date: March 6, 2009
Time: 12:00 pm - 1:00 pm
Phone: 866-565-6580
Passcode: 9593452

Please call at least 5 minutes before the conference call begins. In addition to asking questions "live" during the call, questions can be forwarded in advance to

Questions of the Week
As a Clinical Director, how do I verify a behavioral health clinician’s CANS certification?

You can verify a clinician’s CANS certification with him or her directly. Upon successful completion of the CANS certification exam, a clinician will receive an e-mail from the Massachusetts CANS Training Project which verifies certification and provides a unique certification key. This is proof of his or her CANS certification, which is valid for two years from the date of the e-mail. The clinician is responsible for keeping record of the certification notice and providing it to the employer. At any time, a clinician can log into the CANS training website and select “Edit my Information” on the right navigation menu to print the certification information.
To enter the CBHI application for the first time, a clinician must have a valid certification key.

Is MassHealth requiring client consent required to enter SED and CANS information into the Web-based CBHI application on the Virtual Gateway?
The CBHI application is being designed to collect the information from the set of questions titled “Identifying Children / Adolescents with Serious Emotional Disturbances” (SED determination questions)as well as the CANS tool itself (either the “Birth through Four” form or the “Five through Twenty” form). If you have begun to use the “paper CANS,” you know that the SED determination questions appears along with the CANS – there is an instruction page, then the SED determination questions on pages 2 and 3, then the CANS tool itself on pages 4-18 for CANS “Five through Twenty” (pages 4-16 for CANS “Birth through Four”). Although they appear together, both on paper and in the CBHI application, the SED determination questions and the CANS forms are distinct.
Since the first release of the CBHI application rollout involves only the information in the SED determination questions, the application makes no provision for obtaining consent at this stage. When the second release is rolled out, however, it will include features for documenting consent as well as revocation of consent for the information in the CANS tool. Provider organizations will be required to obtain consent using a form prepared by EOHHS and to certify in the CBHI application that such a consent was obtained before entering information from the CANS forms. We will provide much more information about the consent form and consent procedures in advance of that second stage.
Providers have the independent responsibility to examine and comply with applicable federal and state privacy laws, regulations and rules as well as their own privacy policies and practices. A provider should determine the circumstances under which data can be entered into the CBHI application and may also design and use additional consent forms and consent procedures, if the provider believes that is needed.
What will be the consent procedure to enter CANS information into the CBHI application?
Although the second release of the CBHI application is still several months away, we provide here a quick preview of the consent procedure. Before entering information from the CANS forms into the application, provider organizations will need to document consent by the member (or other authorized person) on the form that has been drafted for this purpose by the state,. The consent form will authorize MassHealth obtain the information and to share it with the member’s Managed Care Entity, to be used for specific purposes.
Prior to entering CANS information into the application, the provider will certify in the CBHI application that consent has been obtained on paper.\The paper consent form, with the signature of the member(or other authorized person), will need to be faxed to the state. Provider organizations will be required to maintain the original signed consent in their records.  If the member declines consent, then the CANS will be documented on paper, and only the demographic and the answers to the SED determination questions will be entered into the application. Members will be able to revoke consent. Consent will automatically expire after a specified period of time, although the form will allow the member to specify a shorter period of time if preferred.

Can other state agencies or other provider organizations see the information in the CBHI application?
No. At this time, other state agencies do not have access to any of the information in the CBHI application. Only clinicians who are within the same provider organization can access a member’s information.

Do you have a question? Email it to us at and we'll e mail you back the answer.

Friday, February 20, 2009

How Could a Foundation Help Children's Mental Heath Reform in Massachusetts?

Today was quite a day.  I was invited by a Family Foundation with an interest in children's mental health services in Massachusetts to talk about what's going on in Massachusetts.  My presentation was based on the Grand Rounds that I presented at Cornell last fall (it's still posted on the web) with some more information about recent events added.  Good presentation, their Board asked very good questions about cost, and feasibility.  In the end, though, it lead to an interesting question:  How can private foundations leverage their contributions to help us all build a better system for children's mental health care in Massachusetts?  The easy answer is "give us money", but it is actually a trickier question than that-  foundations know that they are not always going to be there to support a project, and want to give their money in such a way as to promote strategic growth.  Here are some of the thoughts that I left them with;  feel free to add your own ideas as comments:

  • Provide parent controlled funds for “wraparound”
  • Train parents for new roles in the process: Board members, parent partners, therapeutic mentors, advocate.
  • Develop cultural competence by teaching families about the culture of the mental health system.
  • Trainings for staff on “wraparound”
  • Support groups for agencies in transition
  • Collaborative office rounds for providers
  • Training in “Evidence-Based Practice” for everyone
  • Support multidisciplinary planning meetings.
  • Encourage schools to participate in teams.
  • Court involvement: GAL Project expansion.
  • Link to dropout or substance abuse prevention projects
Many of these are things that cannot or unlikely to be supported by Federal or State funds, so they would benefit from outside support.  Thanks to all the folks who gave me ideas over the last few months.  Got to catch a plane.  See you all next week.

Thursday, February 19, 2009

A Busy Week: Check out Judith Warner's Column today

I'm in Buffalo today, and will likely blog about this meeting later. In the meantime, however, check out Judith Warner's column in today's New York Times. What we are doing in Massachusetts is clearly needed around the country, especially if we are able to show that it makes a difference.  Really good column.

Wednesday, February 18, 2009

Why We Serve: Reflections on an Interview Day

So, I haven't shared with you all that I am in Washington today, at an important interview (no, not with the Administration-don't need that rumor starting up.)-  more about that if I am successful.  But it does make one think about why people serve, and I saw a copy of President Obama's Lincoln Day speech that deserves to be seen.  I am embedding the "Youtube" links, for those of you who haven't seen it yet.

This is part two.

I'll be back later, focused on mental health care. Later.

Tuesday, February 17, 2009

Setting Reasonable Expectations: Screening in the Literature

Alison Schonwald and her colleagues at Harvard made a useful contribution to the literature this month in Pediatrics, the journal of the AAP, with an article titled "Routine Developmental Screening Implemented in Urban Primary Care Settings"-  the abstract is available for free, but my academy has not yet opened its contents to the world without a subscription.  They describe the process of integrating the PEDS into two pediatric practices in the Harvard system, and spent time looking at the impact of that transition on the systems in which they practice.  To me, two things rang out loudly, that should inform our discussions:
1)  What do we call success?:  In academic practices, with the option of EASY access to a second level screening at no extra cost,  they were able to increase the rate of screening from 15% to 61%.  It will take more than a mandate to get kids screened-  it would be interesting to know why kids in this setting were not screened, and we shouldn't expect it to be much better quickly in non-academic settings with less facile access to second level screening.
2)  What are we likely to find?:  In young children, the RATE of identifying behavioral concerns increased, whereas the providers we pretty good at finding developmental problems before screening was implemented.  Overall, we are still talking about a small number of children, and NONE of the ones that they found rose to the level of SED.  These data suggest that behavioral screening under age 2 is UNLIKELY to find much SED.  Should we really be screening them 9 times over 2 years to find so little?
In kids over 2,  the providers were already pretty good at finding the behavioral problems-  the benefit was in the identification of more developmental problems.  And the rate at which they were positive is about 10%.  MOST OF WHICH DID NOT REQUIRE REFERRAL.  This is not too different from the early MassHealth data; we are finding problems, but not overwhelming the system more than we had done already.
Alison is to be congratulated for her perseverence at getting this important work into the literature.  With Karen Hacker's work on older children, it gives us a firm grounding on which to base our policy recommendations.

Monday, February 16, 2009

From the Mass Behavioral Health Partnership: More Benefits

Effective immediately, Chapter 766 testing has been reinstated as a covered benefit for MBHP
Members. Requests for 766 educational testing should be made on the Psychological Evaluation Request form (PER), which can be found on the MBHP web site at The PER form should then be faxed to MBHP at 617-790-4129, with the fax cover sheet labeled as “Request for Chapter 766 Educational Testing.”

Effective immediately, up to four units have been reinstated using the procedure code 99402. Providers may bill up to two pre- and two post-testing counseling units, authorization free, per Member for a rolling 12-month period. If a provider feels that additional units are needed, he/she should call the Outpatient Review Department at 617-790-5634 for a medical necessity review.

If you have questions regarding this Alert, please contact our Community Relations Department at 1-800-495-0086 (press 1 for the English menu, 2 for the Spanish menu, then #3 then #1 to skip prompts), Monday through Thursday, 8 a.m. to 5 p.m., and on Fridays from 9:30 a.m. to 5 p.m.

Elizabeth O'Brien, LICSW
Regional Director
MBHP, Central Mass
120 Front Street, Suite 315
Worcester, MA 01608
Office: 508-890-6406
Fax: 508-890-6410
Cell: 617-645-6219

Friday, February 13, 2009

Screening the Young Ones: What Makes Sense

As you have read here before, the first step of the Rosie D. settlement is universal screening for mental illness at ALL EPSDT visits.  But when do these visits occur in the life of a child?  According to the EPSDT schedule approved by MassHealth, they happen at the following times
occur at the following ages, at a minimum: one to two weeks, one month, two months, four months, six months, nine months, 12 months, 15 months, 18 months, two years, and then every year until the member’s 21st birthday.
So we see children 6 times before their first birthday and 3 more times before their second birthday.   And yet, we don't know how to diagnose a "serious emotional disturbance" in that age group;  at least, I don't.  What we know how to do at that age is diagnose developmental and behavioral problems-  developmental delay, speech delay, autism-  those I know how to diagnosis.  ADHD, depression, bipolar disorder and the like,  I do not know how to diagnose in children under the age of 3.  And yet, because of the EPSDT schedule,  that has become the focus of our early screening efforts.
Three screening tools are approved in that age group at:

The   PEDS: 10 questions that take 3-5 minutes to complete, with open answers, fuzzy criteria for referral, and are hard to score positive or negative, as it includes the "watchful waiting" middle stage.  At 2 weeks, parents think it silly to answer a question about learning preschool skills.  Even at 4 months, that question doesn't make much sense.  The two questions that would detect "emotional disturbance" ("do you have concerns about how your child behaves" and "do you have concerns about how your child gets along with others") are really not relevant in young children.  I think that the PEDS is a great way to assess child development, although I wish that the scoring was more cut and dried.  I doubt it does much for SED in the early years, because we don't know how to diagnose SED that early at that age.
The ASQ-SE:  22 to 36 questions that take 15 minutes to complete and 1-3 minutes to score, and NOT built to be used under 6 months of age.  the plan is 6/12/18/24 months.  The downside to this one is that it takes so much time, and it costs a bit more;  still, wouldn't be unreasonable.
The M-CHAT:  23 questions, easy to score, but specifically screens for autism, not SED.  Designed for use in 18 and 24 month olds.

So we are screening lots of kids with screening instruments that don't find the thing that we are looking for, and upsetting parents in the process.  What would make sense?
My 2 cents:
1)  No evidence to support screening kids under 6 months of age for SED-  we should screen them for developmental problems, and for maternal depression, if you like screening (lots of evidence that that happens).  But nothing for the remedy yet.
2)  At 6, 12, 18 and 24 month, the kids should be screened with a PEDS, an ASQ-SE or an M-CHAT.  After that annual screening will suffice.
3)  We need to continue to work to develop better screener for the younger kids.  Of prime importance is figuring out what it is we are screening for.

The Mass AAP is working on formulating some recommendations in this area.  What do you think?

Thursday, February 12, 2009

The Budget and Rosie D

So, according to the folks out in Springfield, their was a motion hearing on the State's request to change the rollout of the new Rosie D services to a longer timeline.  The details are available on the website;  it looks like the judge is really skeptical of the State's claims that fully funding Rosie D will force the state to cut services to other MassHealth recipients.  Read all about it here.  Two things struck me:
1)  How the law focuses on the case at hand without looking at it in the context of the big picture.
2)  How easy it is to resort to hyperbole-  no one is talking about not treating children with wraparound-  we are just talking about the rate of speed of the change?
As one who treats many children who do not fall into the Rosie D. class, I am disturbed by the thought that the remedy will be extracted from their care.  I am glad that I don't have to make the call- someone will lose no matter what.

Wednesday, February 11, 2009

For those of us trying to understand the budget

As DeForrest Kelley would say when confronted with an alien bookkepper bearing spreadsheets on an old episode of Star Trek, "I'm a doctor, not an accountant" (well, he would have said it if such a creature had existed).  I am still striving mightily to understand the budget, but recently discovered (props to Julie for this) the Massachusetts Budget and Policy Center, which breaks things down in a mostly understandable format.  Try it, you'll like it.  And I promise, no more 1960's era television references!  I'll be back with more when I understand the budget.

Tuesday, February 10, 2009

From Family Voices: Blue Cross and Neuropsychologists

This might be of interest to some of you.
From: On Behalf Of Claudia B Rutherford PhD
Sent: Monday, February 09, 2009 11:48 AM
Subject: [MassFV] Fwd: Blue Cross Blue Shield issue

I don't know if any of you with BCBS insurance are aware of this yet,  but starting in May, BCBS is making some major changes to their policy for authorizing neuropsychological testing. Right now if you have BCBS HMO insurance, you can ask your pediatrician for a referral for testing for your child, and they can get one automatically by computer. It covers 16 hours total which is usually enough or more than enough to cover the testing, report writing, and so on. If you have a BCBS PPO plan, you don't have to go through the pediatrician at all and there is no cap on hours.

 As of May for the HMO plans and July for the PPO plans, BCBS is going to change their policy so that if you need neuropsychological testing, you will have to have the pediatrician and/or psychologist fill out a request form and get permission from BCBS to proceed. They are reducing the total number of hours allowed for children to 8-12 hours total. They will be using a set of criteria to decide whether or not to approve the testing that are proprietary, called InterQual. These criteria are not publicly available and are rumored to be very  restrictive. They are also saying that they will only authorize  testing for ADHD if they feel there is a good case for difficulty making the diagnosis, and they won't authorize testing primarily for educational or vocational purposes (like to help clarify a learning disability).

They are also saying that if you have an HMO plan, you cannot go to a BCBS PPO provider anymore to get testing, only an HMO provider. This is a problem because in many parts of the state, individual providers have not been able to get on BCBS's HMO panels, only the PPO. In the past if a psychologist was a PPO provider, they were allowed by BCBS to see HMO clients, but this will be changing. This means that in some parts of the state if you have a BCBS HMO plan and you want your child to have neuropsych testing, you will only be able to take them to a clinic or group practice to get it done, not an individual in private practice. In some parts of the state not only does this restrict who you can go see, but it will increase your waiting time to get your child tested.

BCBS has not been very responsive to concerns on the part of psychologists regarding these proposed changes. It may be that the only way to make a difference is to speak out as BCBS customers. If anyone is interested in finding out more, please feel free to contact me. If people don't make noise about this it will go through and there will be a deterioration in care for many children in the state. This also sets a bad precedent for other insurers in the state to follow.

Claudia Rutherford

Monday, February 9, 2009

The Budget Again: What have they done this year?

The Massachusetts budget process begins with the filing of H1 by the governor.   That happened last week, and it had a bit of good news with a whole lot of uncertainty wrapped up in its tersely worded lines.  For those of us interested in Children's Behavioral Health,  the good news was in a portion of the bill labeled cryptically OUTSIDE SECTION 17.  (And my thanks to the excellent policy people at Health Care for All for understanding this process much better than I do)  The Governor has proposed bringing the benefit package for the Children's Medical Security Plan up to the standard enjoyed by Medicaid, including dental and behavioral health.  That is very good news for those of us who work with children.
The down side is that a lot of the line items that deal with children's mental health, including the CBHI and other aspects of the implementation of Yolanda's Law, have been rolled into one big line item,  4000-0700,  which includes EI, Nursing Home Supplements, Commonhealth and 6 other things.  On the budget, it looks like an expansion from $1,535M to $3,361M, but when you go back and add up all of the consolidated lines,  last year would look like $4,145M was present in all of the lines that have been consolidated.  That would be a cut, except that some of the consolidated lines were split into two other lines, and it is hard to know exactly how they were split without a really detailed spreadsheet.  Health Care for All felt that the funding for Medicaid expenditures was roughly level, but, I have to say that it is really hard to get a clear idea from reading the budget.
We will keep watching.  It is clear that, until the budget is substantially redrawn, it will be difficult to tell what is being done, and what it being cut in these hard economic times.
Addendum:  Look at the MassHealth website here-  more detail on the breakdown, and this table make it easier to understand how things fit together.

Saturday, February 7, 2009

A Bit of a Digression: The Health Care Reform Debate from the Left

As you might have noticed, there is a lot of talk around the country about reforming health care in America.  Most of the conversation is about reforming the mechanism of payment for health care, but there are also those of us who are interesting in developing systems of care that go with the new payment system. I haven't much about payment on this blog, although it is more or less the elephant in the room.  Our new systems of care, in mental health or in health care in general, will need a payment system.  So, on this Saturday, I took advantage of a discussion sponsored by Physicians for a National Health Care to hear the arguments for a "single payor" system over the "mandate" system currently being instituted in Massachusetts, and advocated in Senator Daschle's book Critical.  This argument assumed that the government has a role in establishing a decent health care system, and moves in the realm of what should that role be.We opened with a talk by Steffie Woolhandler, who began by defining the problem, an argument that she has made in many articles and journal.  Uninsured and underinsured patients are rampant,  we are rationing health care in the face of a surplus of resources that are distributed in a way that doesn't match the needs of the people.  And her estimation, many of the problems can be traced to the addition of profit maximization to the business of medicine.  The key to her thinking is the "20-80" rule-  20% of the patients are responsible for 80% of the cost, a fact which drives insurance companies to do many things that fall under the category of cherry-picking.  Listening to her talk, and reading her literature (here, and here for example),  it is hard to see a place for profit in the business of medicine, a thought echoed by the Health Care conversation we hosted last month.So what, you may ask, about the argument that we can't afford national health insurance? It turns out that, between the cost of health insurance and lost tax revenue, we are already paying much more for our non-system than most countries pay for their systems.  (She showed some bargraphs with this information)  She also also pointed out that a National Health Plan is the only way that one can get a handle on cost control (market forces haven't managed that)  It seems to be the right answer, and yet, to talk to many folks in government, it is politically dead in the water.  So, how do you make it happen?  This group of people feel that this can happen and that the problem is how to address the powerful interested that are currently managing the profit in the system.
I went to the workshop on tough questions, because I wanted to hear that was perceived as the tough questions in this debate.  The attendance at this meeting is interesting;  a mix of doctors and non-doctors, supporters and learners, all focused on the question of single payor.  
#1:  What about the waiting lines in Canada?  We know about the waiting lines in Canada, because in Canada they measure it, and they try to fix it.  Here, there are lines, but they are a private tragedy instead of a public discussion.  Others suggested looking at "phantoms in the snow", an article that looked at this problem.
#2:  Why is no one talking about the way in which "fee for service" payment warps the way in which we practice medicine?  One of the side effects of a fee for service system is the perverse incentives to specialize, increase the flow of patients and only do that for which they get paid.  Good argument for a salary based system.
#3:  Why can't we just regulate the insurance industry?  A movement strong enough to regulate the insurance industry is a movement that is strong enough to create a single payor.  Why not go all of the way.
#4:   A more efficient system would but hundreds of thousands of people will be swept out of work.  What about them?  Part of the reform would have to be retraining the folks that make up the currently bloated administration system within the insurance industry.  There likely will be things for them to do.
How does this happen on the ground?  They think that the debate is go on for a long time, and that we need to keep single payor in the conversation while the discussion is going on, and that the single payer will move up on the list.
We reconvened to talk about health care to business, and that led to an interesting discussion of framing.   I will try ot reconstruct the argument.  First, one must get the business point of view:  we are paying too much for healthcare, costs are high because people are using too much care, they are concerned about the insured, not the uninsured and and they, in general, don't trust the government.  Business folks think in terms of systems, budgets, fixed cost or efficiency;  we need to frame the discussion in those ways.  So, with that in mind:
  1. Few people are using health care at any one time (we all use it eventually)  Remember the 80/20 rule.  80% of health care uses less than $1400 per person.  Cost is in the top 20%.  Either share the burden, or fight to avoid it.  So health care administration is largely devoted to avoiding payment of the top 20% of costs.
  2. Most costs are fixed.  Fixed costs are 70%- salary and infrastructure.  We want the services to be there when we need it, and we don't know what how much that is, because there is no system. 
  3. We are already paying the whole bill.  Who should be responsible?  Not clear-  we finance the services on a "wing and a prayer".  The financing is based on cost shifting, with the public as a back up.   In the end, we have a system that is funded by taxpayers (60%), business (20%) and out of pocket costs (20%). 
  4. We don't have a system so we can't fix anything.  This is the ultimate problem.
Why do other counties do it better?  Administrative simplicity, negotiated prices, more primary care and prevention, health planning and global budgets.  They have a system, and they use it to improve the health of the population.  A National Health Plan will allow us to do the same thing.
It was interesting that they chose to focus on a model business talk during this session;  it underlines the need to align the interests of these "liberal" doctors with the business community if we are to make progress.  She thought that there are a lot of "closeted" businesses that want to move the government into the leadership business community.
MassCare:  Critique of Health Reform.  So, to start with, we have health reform:
>300% FPL  :  You must buy health insurance
How is it going?  Depends who you talk to.
While people support the law,  it is (mostly) costing more. We have insured a lot of new people, but some of the new rules include more restrictions on folks who used to be cared for by the free care pool.  The biggest problem is the 10 day rule-  many patients do not apply for Commonwealth Care in time, and then are denied care.
Individual mandates:  Effectively, this is a "poll tax"- a regressive tax that punishes those with less money.  It blames those without insurance for their problem.  Not a great way to run a system.  (But is that worse than funding SCHIP from a cigarette tax)  
Affordability:  The folks who are buying insurance are buying high-deductible plans, which actually is costing the CHCs more money, as folks often don't pay their deductible.  
Safety net providers:  All of this is causing a budget crisis in the safety net institutions.

He is pretty pessimistic about this approach:  this said that Minnesota was unable to reduce the percentage of folks who are uninsured in 1993.  Neither were Tennesee or Oregon.  All ran into the problem of rising costs.

His conclusion:  "You can't cross a chasm in small steps."

Interesting graphic.

Dr. Woolhandler referred to this as "robbing from the poor to give to the poor."  They strongly feel that it is likely to fail.
I then went to the session on "how to talk about single payer".  She used the "iron triangle" of cost, quality and access, as the framework for the argument;  she made the point that the argument needs to be framed differently for different audiences.  Business, as noted above, will be interested the business argument.  Labor, it seems, can be approached by the ability to take health care OUT of their collective bargaining sessions.  Another point was the "framing" of the question of choice:  patients want choice, not of a health plan, but of doctor and hospital.  The Harry and Louise ads conflated those two ideas.
So, what did I get out of today's discussion?  My belief remains that our current systems are too complex, and do not create the kind of health care that we want- wholistic, based on science and founded in the relationship between a family and a doctor or nurse practitioner.  We would benefit from a drastic simplification of the payment system, and such change would make it easier to begin the process of reforming the delivery system.  I don't see America accepting a single payor system, whether for health care or the phone company, even though it would make lots of sense.  Massachusetts is trying mightily to make the politics work toward creating a system that is closer to the ideal;  it is not there yet, and the process of change is messy.  It will be messier still on a national level.  The clearer we can make the message, the more likely we are to succeed.

Wednesday, February 4, 2009

UPDATE: President Obama Signs CHIP Reauthorization!

Interesting commentary here.


A few minutes ago, President Barack Obama signed into law the reauthorization of the Children’s Health Insurance Program (CHIP). Though our nation endures uncertain economic times, we are pleased that the White House and Congress came together on this issue to wisely prioritize children’s health.

Once again, we express our sincere gratitude to you for your efforts in contacting your members of Congress on behalf of CHIP. This was a team effort! Your support and efforts on this legislation over the years was critical to our success and we share this victory with you and millions of families across our nation.

The reauthorization of CHIP means that more than $30 billion in federal funding will be available to provide health care for those currently enrolled in the program, and to enroll millions more children, the vast majority of whom are currently eligible for CHIP or Medicaid but unenrolled. The legislation also includes the Immigrant Children’s Health Improvement Act (ICHIA), which will lift the five-year ban on eligibility for legally residing children and pregnant women in force since 1996.

While this accomplishment is significant, we know that CHIP reauthorization is not health reform for children—it is a bridge to what should rightly come thereafter, broader health reform to ensure that all children have access to affordable, high quality health coverage. The American Academy of Pediatrics looks forward to working with President Obama and leaders of both the House and Senate in the coming months on broader health care reform.

To learn more about other AAP advocacy initiatives you can be involved in, please visit


And more good news:
Office of the Press Secretary
For Immediate Release February 4, 2009
February 4, 2009
SUBJECT: State Children's Health Insurance Program
The State Children's Health Insurance Program (SCHIP) encourages States to provide health coverage for uninsured children in families whose incomes are too high to qualify for Medicaid but too low to afford private insurance. Since 1997, when SCHIP was enacted, States have had the authority to set their SCHIP income eligibility levels, subject to available funding. In recent years, as the cost of private insurance has increased, States have raised eligibility levels to offer health care coverage to more families, with families paying a share of the cost based on their income.
On August 17, 2007, the Centers for Medicare & Medicaid Services (CMS) issued a letter to State health officials limiting the flexibility of States to set income eligibility standards for their SCHIP programs. On May 7, 2008, CMS issued a subsequent letter restating the policy set forth in the August 17, 2007, letter.
The August 17, 2007, letter imposes additional requirements that States must meet in order to cover children under SCHIP plans, including plans that CMS had previously approved. These requirements have limited coverage under several State plans that otherwise would have covered additional, uninsured children. As a result, tens of thousands of children have been denied health care coverage. Unless the August 17, 2007, letter is withdrawn, many more children will be denied coverage.
By this memorandum, I request that you immediately withdraw the August 17, 2007, and May 7, 2008, letters to State health officials and implement SCHIP without the requirements imposed by those letters.
This memorandum does not create any right or benefit, substantive or procedural, enforceable at law or in equity by any party against the United States, its departments, agencies, or entities, its officers, employees, or agents, or any other person.
You are hereby authorized and directed to publish this memorandum in the Federal Register.

Tuesday, February 3, 2009

Systems and Relationships: The Tension at the Heart of Rosie D.

I am giving a presentation to a private foundation in a few weeks, about the current efforts at mental health reform in Massachusetts, and where we are going.  On the train, on the way in, a thought occurred to me:  at the core of a family-centered mental health system is the relationship between the family and the therapist/doctor, that relationship, critical though it is, is hard to capture in an outcome measure, and that evidence-based practice may not be the best way to get to a relationship-centered system.  So what what do I mean by this?

1)  At the core of a family-centered mental health system is the relationship between the family and the therapist/doctor:  There is actually a literature on this, the famous "what do patients want" studies.  Ten years ago, an early website (they build the internet with stone knives and bearskins, you know) asked that question, and got a plethora of responses that all meant relationship.  Last year, a more formal study in South Africa showed that we want 

"values in a doctor that range from fairness, lack of discrimination, autonomy, dignity, warmth and taking time to do a job properly. .... The definition of a good doctor as provided by the participants was not based on strict technical/clinical criteria, but rather on the patients' and the community's recent experiences of care under that particular doctor. The typical good doctor is a popular, friendly person who does not discriminate along racial lines, listens seriously to anything presented to him or her and examines the patient properly. He/she takes the patient's illness seriously, refers when necessary and gives sick leave that can be used to see a traditional healer. "
No surprise there.  Whether a primary care doc, a specialist or a mental health therapist, we want a doctor who is smart,  listens well and understands where we are coming from.  It is the relationship that we crave.
2)  that relationship, critical though it is, is hard to capture in an outcome measure,  Is the only way to measure relationship is to ask about it?  We certainly do that a lot, but, in general, most of our patients like us a lot.  Deborah Roter talk us how to tape record the interaction and analyze it for quality.  Either way, surveys or tape recordings, this is not data that is easy to capture.  Sometimes we survey some patients, but these are not the outcome measures most commonly used in assessing the quality of a system.
3)  that evidence-based practice may not be the best way to get to a relationship-centered system.  The evidence that we use is based on studies and surveys and other things that are not geared to assess the "goodness" of  the relationships that we are forming.  The evidence is based on impact on depression scales, and hospital/ER utilization and missed days of work- longer term outcomes that often follow on good relationship.  Unless we take care to measure the intermediate outcomes of patient satisfaction, there is no reason to think that we are going to get our system of care to the place that patients want it to be.

Therein lies the dilemma of Rosie D (and all other efforts to build a mental health system).  We want the system to be comprehensive-  that means we need a system build on evidence, funding those things that work.  To know that it works, we must study it outside of the context of the relationship that makes it possible.  It is altogether too easy to forget that we need to allow the evidence-based piece to be placed in the context of an ongoing relationship;  otherwise the people will find themselves teated as robots.  Not good; the relationship is the glue that holds the whole thing together.  The Parent Partners, the collaborative approach, the family inclusion in the wraparound model-  all of these things are meant to meet the expressed need of the patient for relationship.  The evidence to support this part of the new system, however, is thin indeed. 

It would be such a simple gift, to make mental health care incorporate the aspects of personal relationship that we all think is critical to its success.  But, as the fabulous four classical musicians showed us on inauguration day,  it is often challenging to do the simple correctly.

Monday, February 2, 2009

Implementing Behavioral Health Screening: What is a good screening rate?

I pointed out last month that, as of the third quarter of the implementation of the Rosie D. Screening process, we had achieved a rate of screening of 40%.  You might ask, is that good?  I argued that it was pretty remarkable for such a new policy;  my opinion seems to be supported by a study by Alison Schoenwald and her colleague's in this month's Pediatrics.  I am impressed that she was able to publish such a QI study;  what they found was pretty straightforward, but also pretty useful.  At Children's Hospital, with training, and an implementation protocol, they were able to move a practice from a screening rate of 15% to 62%.  Most of what the children identified in the screening had speech delay and needed audiology or EI services.   Many of the screening failures, it turns out,  happened because the children were brought in by someone other than the parent.  No surprise, that happens to us all of the time.  
I will be surprised if the fourth quarter numbers are much about 50%, based on those numbers.  Takes a lot of work to get this screening stuff to happen.
By the way, P Phil, the groundhog saw his shadow and ran away.  It really will be a long cold lonely winter.

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