Tuesday, June 30, 2009

Thank for your help: My Fellowship is over.

The woods were dark and deep (and wet),
And I must have some sleep (you bet).

Last week was my reintroduction to clinical practice- as I mentioned when I started this thing, I am a primary care pediatrician who has been given an extraordinary opportunity by the Center on Medicine as a Profession to spend a significant chunk of my time exploring ways in which a primary care pediatrician can advocate for improvements in the children's mental health system. I have worked with coalitions, written articles and op-ed pieces, given testimony, organized "events", hosted meetings, given talks on children's mental health, all with the intention of building a better system in Massachusetts (and eventually the world). Along the way, I have come to understand a few things:
1) There is a lot about children and mental health that we don't know.
2) Families are the key to managing children with mental health issues.
3) Medications are useful, but not an answer without the rest of the system.
4) This is going to be difficult, and take many years to get right.

In my work, I've gotten to work with advocacy groups like HLA and PAL, clinical groups with the UMass MCPAP team and the WMHN and state-sponsored groups like CBHI and MBP. All have been helpful. I have watch a bill make it through the State Legislature, another go through the Federal one, and watched as dedicated public servant drew up the blueprints for a new system out of whole cloth. I think that, on the whole, I have contributed positively to the process.

Tomorrow, my funding is done; as of July 1, I am back to being a full-time pediatrician, cranking through the patients and trying to do right by them. Of the 25 kids I see most days, 3or 4 will have serious emotional disturbance. Half of those will already be in some sort of treatment; the rest will need help getting there. I'll be trying to work with CSA on this; in the long run, however, that is not going to be good enough. We need the promise of the CBHI to be fulfilled and that requires that each of us think hard about how to help the CBHI achieve its maximal potential. With that thought, I close. Thanks for your help; now the real work begins.

Oh, don't think that you've heard the last of me- I will keep posting. Probably not as frequently, but there is still much to do.

Monday, June 29, 2009


I was poking around the Massachusetts Behavioral Health Partnership's website, and would recommend those of you who want to see what happens next to the Massachusetts Behavioral Health Partnership website, which has assembled a lot of useful information in avery usable format.  I particularly like the list of contracted providers (here) and the revised structural slide, which adds complexity to the already complex system.  Good luck to the boots on the ground!

Sunday, June 28, 2009

A respite of sort: Two days until CBHI

So, I just typed in a blog entry on my i-phone, because I wanted to see if it work, and when I pushed the publish button- blip- it disappeared.  Frustrating.  Let me try again:

In a little under 48 hours, the final phase of the Children’s Behavioral Health Initiative will be implemented with the start of the 32 CSA contracts across the Commonwealth.  Personally, I don’t expect everything to change at once, but, having spoken with a number of the people doing this work, I do expect to see some changes in the way in which services are delivered in Massachusetts.   It will not be easy- change never is.  But it will be interesting.

I have heard a lot of people trying to frame the various new services in terms of what has gone before.  If that is all that we are able to do after the massive political effort that has been mounted in the Commonwealth over the past 4 years, I will be disappointed.  I thought that, at this juncture, I might put forth some ideas about how I will be looking at the CBHI to mark success.

1)  Are families actually engaged in the process, and is that engagement strengthening their resilience?  The bad stuff that we associate with mental illness, such as  suicide, homicide, crime and homelessness, is all associated with people who live outside of the protective bonds of families.  “Protective factors” such as strong families have been shown to help to prevent those outcomes.  If we are not, at a bare minimum, strengthening families, then this effort has been in vain.

2)  Are the interdisciplinary teams forming, communicating and collaborating in the care for children with SED, and does that collaboration affect the type and quality of the care delivered?  It has been an article of faith among us that collaboration will lead to more efficient allocation of resources because of the avoidance of duplication of effort.  We should test our faith;  does it actually work in the real world?

3)  Are children with SED better able to function in their communities?  Whether school, daycare or the YMCA, this initiative needs to be about integrating children into the community.  Our success should be measured by some sort of community integration metric;  otherwise we are just creating a new set of institutions?

4)  Have we created, in the hearts and minds of the Commonwealth, a sense of parity between children with physical handicaps and children with mental illness (and children without any of these things)?  This is a truly long-term goal, to reduce the stigma of mental illness to the point where children enter treatment early and are well managed before they develop SED.  I have watched with dismay that the word SPED (special education) is often thrown about the schoolyard as an epithet.  We cannot allow the same to happen to SED.

So, perhaps I am setting the bar a bit higher than “compliance with the court order”, but we really should be looking at the data that rolls through the CBHI to see if these things are happening.  Perhaps the Child Behavioral Health Research Institute envisioned under Yolanda’s Law can do this.  When we have de-stimatized family-centered interdisciplinary care that allows children with serious emotional disturbances to function in the community, I will think that we have done something meaningful for the lives of children.

Thursday, June 25, 2009

They are coming: A word from the Partnership.

I've been in the office 3 days this week, and in the Berkshires 3 days;  I've identified at least 6 families that have Masshealth, a child with SED and a need for ICC.  One has already told me that they can't get in to their local agency for the intial CANS evaluation.  In other words, it begins.   Here is what the CSAs are going to look like, according to the MBHP folks.

A Community Service Agency (CSA) is a community-based organization whose function is to facilitate

access to, and ensure coordination of, care for youth with serious emotional disturbance (SED) who

require, or are already utilizing, multiple services or who require or are already involved with multiple

child-serving systems (e.g., child welfare, special education, juvenile justice, mental health) and their

families. In total, there are 32 CSAs across Massachusetts: 29 that provide services in the geographic

region consistent with the current 29 service areas for the Department of Children and Families (DCF)

and three culturally and linguistically specialized CSAs to address the needs of specific cultural or

linguistic groups in Massachusetts. Geographic CSAs and specialized CSAs working in overlapping

areas are expected to collaborate and partner in ways that strengthen services to youth and families.

The chart below is intended to assist potential referral sources, including families, in identifying and

selecting an appropriate CSA to meet their needs. Consistent with the Wraparound principle of family

voice and choice, families may choose from any CSA based on their needs and are not limited in using

the CSA in their geographic area. For the 29 geographically-based CSAs, towns are listed

alphabetically, followed by the (DCF) area, the CSA, the site(s) where services will be delivered, the

referral phone number, and other relevant information if available (i.e., contact person, e-mail address).

A town is assigned to a CSA based on the DCF area office that covers that particular town.

Additionally, the three specialized CSAs, which have tailored their services to engage and serve the

unique needs of their specialized populations, are listed separately at the bottom of the chart, identifying

the towns each covers, the specialty population, the site(s) where services will be delivered, the referral

phone number, and other relevant information if available (i.e., contact person, e-mail address). An

asterisk (*) next to a geographically based CSA town indicates the town is also covered by a specialized


If you have questions regarding this Alert, please contact our Community Relations Department at

1-800-495-0086 (press 1 for the English menu or 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.

Wednesday, June 24, 2009

Learning About Change: CBHI to Present at 5 Massachusetts Health Care Training Forums in July

From the CBHI:  
Are you or your staff interested in learning more about CBHI, screening and assessment improvements for MassHealth-enrolled children and youth or the new behavioral health services that will begin next month?  Key CBHI staff members are scheduled to join other topic speakers at the upcoming Massachusetts Health Care Training Forum (MTF) series being held at different sites around the state in July.  Click here  for a list of dates, a registration link and to find a forum location near you.
Note: The Massachusetts Health Care Training Forum (MTF), formerly called the MassHealth Training Forum, is a partnership between MassHealth and UMass Medical School. Their quarterly meetings are designed to bring accurate and timely information related to MassHealth (as well as other public assistance programs) to health care and community agency staff serving MassHealth members, the uninsured, and underinsured. For more information about July’s forum, and others, call MTF at (508) 856-4306 or visit their website.

Tuesday, June 23, 2009

From the MCHB newsletter

Got this on my e-mail today. Interesting, and possibly useful to our task.

Mental Health Needs of Low-Income Children with Special Health Care
Needs (CSCHN) summarizes a study that compared the prevalence of mental
health problems among CSHCN to family perceptions of mental health needs.
The issue brief focuses on what was learned from a Child Health Insurance
Research Initiative (CHIRI) survey of families of CSHCN enrolled in Medicaid
receiving services in six primary health care clinics in an urban Midwestern
city. Family perceptions of their child's mental health needs were compared
with the results of the Child Behavior Checklist, a standardized tool that
uses parent report to assess emotional, behavioral, and social problems in
children. Data on the percentage of health and mental health problems in
CSCHN in Medicaid and family perception and need for mental health treatment
by age are provided. Policy implications are also discussed. The brief is available at http://www.ahrq.gov/chiri/chiribrf9/chiribrf9.pdf.

Monday, June 22, 2009

Pondering NPR While Commuting from the Woods

An odd schedule this week; I am seeing patients while camping near that beautiful view you all saw in yesterday's post. My first 3 patients did not come in for their appointments, and I have time for a quick blog entry on one of the stroies that I heard on NPR which cruising (at the speed limit) down the Massachusetts turnpike morning.

You can hear the story here, I will sumarize it for you. Patients, particularly complex elderly patients, are finding that they need an advocate within the system, who understands their needs and desires and understands the multifaceted health care system well enough to guide you through the system. They highlighted two models- one was volunteer retired physicians and nurses who work with hospitalized patient and are able to ask the questions in such a way that the system would respond. The other was what I would call "concierge nurses" who coordinate care for folks in assisted living, helping to keep them out of the hospital. The story ends by pointing out that noone wants to pay to support these services, and suggested that we need data to justify this fairly self-evident cost to the system.

Both of these groups of people do what your primary care physician no longer has time to do; know you so that you can be known. The similarities to the impending ICC program seemed to suggest a similar trap lay ahead for us. As we roll out the CSAs, we need to be sure to collect the data to justify this cost, as we certainly believe that it is part of the cost of doing business.

Patients are here- got to go.

(And I just added a picture of the swollen stream near our campsite. )

Sunday, June 21, 2009

A Pause in the Process: Heading Off to the Woods

So, unless my good friend Chris Stille wants to fill us in on the relationship between the Medical Home and the Children's Behavioral Health Initiative, you may see a dearth of postings over the next week-  I'll be splitting my time between seeing patients in the office, and camping in the Berkshires.  (We are little short-staffed this year, so I'll be in and out of the woods).  I may post some things, but I will likely be in a hurry to get back to the woods.  So, I wanted to post an image of our usual campsite, so that you all will understand my desire to get back to the woods.
I'll be back full time on the 28th of June.  Enjoy the picture in the meantime.

Friday, June 19, 2009

Practice Today: What will it be like next month?

So, after my presentation this week, I became a primary care pediatrician again, seeing kids for camp and kindergarten, poison ivy and swine flu and the ever present behavioral health problem.  Summer is actually the time in which I usually see the few behavioral health issues, I think;  stress decreases as the schools are close, the kids can run around outside or visit their grandparents and many families seem t have a bit more room to cope with life.  Many of the kids who don't have behavioral or mental health issues come in for their annual physicals, and I get to see a lot of high school graduates who are on their way to college.  Still, this year, this annual unwinding of practice tension has been complicated by the swine flu outbreak and the loss of practice supports as a consequence of the state budget crisis.  We are still seeing flu still, which is decidedly odd this time of year and it is keeping us busy, and our DPH-funded care coordinator will have her last day with us on June 30, 2009 (truly unfortunate- we've had a care coordinator since 1996 and it has allowed us to be more proactive in our support of families).  As the CSAs ramp up, the rest of us are ramping down.  As I have said, this will be an interesting transition.
In the midst of this, I have had several youths who worry me:
1)  A young man previously diagnosed with ADHD who took himself off of medication this year, barely passed the 7th grade and had a PSC score of 46 at his annual physical.  I think that he has agreed to talk to his therapist again, and consider reevaluation- I think that bipolar may be a better description for him than ADHD.  PSC screened positive- now he needs to get into the system.  Sadly, he has private insurance, so the wraparound won't help him.
2)  Another youth in his senior year with a therapist, a psychiatrist,  a history of a failed suicide attempt this year and a PSC of 26 or so.  His affect was worrisome, but he assured me that the therapist had it all covered.  Still, he was actually better than last year;  I hope he graduates and that things get better for him.  
3)  A young lady with ADHD, who seemed to be doing OK on her meds, but whose attitude toward school took a nose-dive in the last semester.  She does not want to talk to a therapist, so we will continue to monitor her status with concern.  MassHealth at least, so if she gets worse, I have some place to send her.
The screening continues, the workload piles up; will we be able to get these kids into the system?  After three days in the office, I see that we still have a lot of work to do to make this system work.

Wednesday, June 17, 2009

How is this going to work?: Some thoughts at a Strategic Planning Meeting

Live-blogging:  I was invited to the Strategic Planning meeting for Central Massachusetts Communities of Care, a SAMSHA funded initiative in our part of the state that preceded the CBHI, and in many ways, is the basis for the wraparound services that we are about  to roll out around the state.  The meeting is in part an annual planning meeting for an ongoing project and in part the kick-off for the System of Care Steering Committee, which will be a key part of the new Community Service Agency.  I was late;  as I entered, I heard descriptions of two "evidence-based" programs PBIS (Positive Behavioral Interventions and Supports) and TF-CBT (Trauma Focused Cognitive Based Therapy).  The PBIS made a certain amount of sense;  allying with the schools always make sense.   The TF-CBT folks claimed that 25% of children  and adolescents have experienced "trauma" (both as victims and as witnesses), and that kids "in the system" have a much higher rate of trauma.  They showed progress in participants who are enrolled in the program.  We also heard some of the participants of the Communities of Care, dealing with some pretty harsh times as well.  Stuff that is hard to measure, but really shows the intrinsic value of wraparound.  We saw some data from the CoC that shows positive benefit of the program (no control or comparison group).  We heard the family voice and the need for the family voice at the table, and the need to break down the language that we professionals use in this work so that families can understand it.  We heard a lot of things;  basically we heard that the model is a bit of work, but is worth it.  
Slipped in to all of these talks, there was a small revelation for me; the Youth and Family Center in Webster (where I practice) is not going to the continue, which is a bit disappointing.  Disappointed, I went off to dinner, and to join a small group.
The small groups focused on three questions:  What are the benefits of the Youth and Family Center?  What would you do if you only had half of the support?  What could you bring to the cause?  Many of us in the group were from Webster; we were all feeling a sense of loss over the loss of the Center.  We recognized the strength of the youth groups and presence within our community;  we offered to support the youth going forward with space and expertise;  we really thought that it was important to preserve the connection that people felt in the Center. 
Connection seems to be the core of the wraparound process-  connection is the part that is really hard to replicate.  We tried to be upbeat, but it was hard.  We returned to the bigger group.
In the larger group, others seemed to be more optimistic than were we;  they spoke of successful diversion, a comfortable feeling, the strength of collaboration with those that have "walked the walk", PPAL and the strength of parent collaboration.  The relationship with the Dudley Court and the availability of respite, the feeling of safety and the support of peers, parents and workers.   The development of parents and youth as leaders works.  All of these things work, and it is sad to see how our economic fallout will hurt so many families.  There is an old saying: "When elephants dance, it is the grass that gets crushed, when the elephants fight it is also the grass that gets crushed".    So what do I take from this?
1)  Families need to be at the center of the process.
2)  Process is everything.  Take no short-cuts.
3)  It is hard to cut any part of the program-  it is an organic whole.
Nice meeting;  a model for what we need to do in the CBHI.  Gives me hope for the process, and trepidation over the outcome.

Tuesday, June 16, 2009

A Talk in the Woods: CBHI in 2 Weeks

So, here are the slides from the talk that I gave yesterday and last week, if you would like to see them.  You can actually download the powerpoint slides here.  Enjoy, and remember, this all becomes operational in 2 weeks.

Monday, June 15, 2009

The President's Remarks to the AMA

The President's speech to the AMA is of some importance:  the Wall St. Journal published it here.  Read it before reading what the bloggers and commentators weigh in.  As you can guess, the comments on the Wall St. Journal are a bit negative.  The game is afoot- time to weigh in.  Here's the first clip I could find.

How Big a Lever Do You Have? Advocating in the Two Halves of the Mental Health System

As you have noticed, most of my posts over the past few weeks have focused on either the evolving settlement of the Rosie D case (in which the judicial branch is telling the executive branch what to do) or the passage of Yolanda's law (in which the legislative branch is telling the executive branch what to do).  It is interesting to compare these efforts a bit, especially in terms of how they will affect the actual mental health services for children in the Commonwealth.

The Children's Behavioral Health Initiative (the public response to the Rosie D remedy) is actively building a new system in response to the court mandate.  There is a lot of negotiation over the details, but noone can argue that the state is building something that is new.  ALL of it is result of the entitlement that is EPSDT;  without that lever, it seems likely that the Commonwealth would have continued to implement incremental change that would perhaps have gotten us to this point by 2025.  That is one powerful lever (the force of court), that makes us all drop what we are doing and attend to this particular issue in a forthright and effective way.

The Children's Mental Health Campaign (Yolanda's Law) is a slower and much more limited process.  The bill sets out a number of processes and reports to hold agencies and more providers accountable for the care they is provided through private insurance plans;  it's power is in the creating of paper trail in most cases, and yet, since 75% of the children in the Commonwealth not on public insurance, it has a much greater potential to impact their mental health.  But it lacks the "teeth" of the court to enforce compliance;  the reports and plans and discussions will work to create a consensus.

My observation, however, is that we are dealing with two very different size sticks.  The lawsuit gives us LOTS of leverage for change.  We can build new systems with that kind of leverage.  The question that one must ask is, will the change last once the court declares the case resolved.  So, even with the force inherent in a court order, care must be given to ensure that there is some consensus and process developed to make the change stick.  The bill opens the door for leverage, but really must be seen as an effort to begin a lengthy reform process.  With a long enough lever, as in the Rosie D. case, we really can affect major change.  Legislative change requires more time and patience, to build a consensus around structural change.  One hopes that the structure will last;  the structures that do last seem to be the ones that afford some measure of political power to those who benefit from the change (ie Social Security lasts because the elderly resist attempts to change it).  So, when the Court is gone, and the Campaign is over, who will stand for the rights of children in the mental health system?  Not an easy question for those who would make this sort of policy.
Talking in Waltham tomorrow.  Hope to see you there.

Sunday, June 14, 2009

Trying to Stay Focused on Children's Mental Health (but failing miserably)

Over the last year and a half,  I have tried to focus this blog on the problems of children's mental health care in the Commonwealth of Massachusetts, as the politics of that time and place were and are creating the potential to create a system that will better service children.  Occasionally, I have drifted into digressions on the current "health reform" debate, that began in the Presidential campaign last year and is now raging in Washington.  It's important, and you bet that I have many opinions about what is being suggested at the present time.  But I am trying to stay focused-  it is important to get the work done.

Last week, however, I spoke of the small group meeting that I attended on Health Reform.  Last winter, I discussed the two "health reform" meetings that I attended when Tom Daschle was still going to run Health and Human Services.  Today, I have to invite you all to weigh in on the "public option" debate.

The health plan that is coming out is going to look a lot like the Massachusetts plan, with employer mandates and cafeteria plans and a lot of administrative fooforall, and, as a denizen of that part of New England, I can tell you getting insurance for everyone does not cut costs unless you include a public option (Medicare for All) in the mix.  It is not clear to me that a voluntary public option reins in cost enough, but I know that it is essential.

I also know that once we start to reign in costs, some doctors and hospitals are not going to be able to bring in as much revenue as they once did.  That will be a problem, particularly for the surgeons and others who currently bring in the most revenue.  But it has to happen or we will not be able to get the system under control.  Last, I know that, if you still want people to go to medical school and not make $200K annually on graduation, we need to figure out some other way to pay for it.  Students currently graduate owing an arm and two legs;  no wonder they opt or higher paying jobs.

The AMA apparently believes that the private sector can do this.  (Although a colleague that the AMA has not finalized it POV on this)  I don't believe that the private sector can do this- infact the historic record suggests the the private sector only does this sort of thing when threatened by a government plan.   What ever plan finally passes, it must have a strong public option to serve as a benchmark for what we expect from the private sector  ( I have a soft spot for single-payer, but I am willing to be flexible)  If you are a doctor or medical student, please tell the President how you feel about this at the Doctors for America website.  Then tell your Congressman.  

Thanks for tolerating the digression.  Back to mental health tomorrow.

Friday, June 12, 2009

Too Much Going On: A Pause for Inspiration

We've got the legislation, we've got the lawsuit, we've go the CBHI and we've also got graduations:  thousands of young people are graduating from colleges, universities, graduate  and professional schools, many of whom look at the mess that we have before us and worry that they might not be up to task.  Graduation speakers around the country have to address that feeling.  I thought that Bill Cosby's address to the Carnegie Mellon graduation a few years ago was inspiring and relevant to the need to bring what we have to the struggle  (Disclosure: My son, Josh, is a rising junior in Physics at that geek-filled institution).  Besides, I like listening to Bill Cosby.  Hope the rain stops this weekend.

Thursday, June 11, 2009

Phase III of the Children’s Behavioral Health Initiative: What Do Primary Care Pediatricians Need to Know

Submitted to the Massachusetts AAP  Forum:

As most primary care pediatricians know, Massachusett’s Medicaid program (AKA MassHealth) in in the midst of a massive reform of the systems of care for EPSDT-eligible children and adolescents with “serious emotional disturbance”.
  Last year, we began screening for behavioral health problems in our practices, and referring those children to behavioral health providers throughout the Commonwealth for assessment and treatment.  For the last 8 months, that system has been assessing those children with a single tool (the Child and Adolescent Needs and Strengths instrument or CANS) to establish a common language for a new kind of treatment paradigm, called “wraparound”, that will be practiced throughout the Commonwealth.  On June 30, the final phase of the Children’s Behavioral Health Initiative begins, as new forms of Mobile Emergency Mental Health Services and Intensive Care Coordination are instituted around the State.  The new system in complicated;  detailed descriptions are available at several websites around the state.  In this article, I want to talk about how this new system will work with you to provide family-centered care for families with children with serious emotional disturbances.

            To understand how this new system will work, you need to understand a couple of concepts key to the system.  First is “wraparound”.  To quote Bruce Kamradt of Wraparound Milwaukee, “Wraparound is an approach to implementing individualized, comprehensive services within a system of care.  Wraparound is not a service or set of services.  It is not a type of treatment like multi-system therapy (MST) or functional family therapy. It is a unique way of organizing services and supports individualized for a youth—it is more of a process that puts the family at the center of care”.  In a sense, wraparound is remarkable like the system of care we pediatricians have proposed under the Medical Home model.  Just look at the essential values of “wraparound” from the Milwaukee model:

  • Build on youth and family strengths, not their deficits
  • Care should be individualized—one size doesn’t fit all
  • Youth are best served in the community
  • Youth/families should have access to the services they need, not just what is available
  • Services should be provided in the context of the family and families fully engaged in the planning and delivery of services
  • Services and supports need to be culturally competent
  • Care should be unconditional—plans fail--not youth!


This sounds an awful lot like the medical home to me.  This model of care will not be foreign to pediatricians.

            So, how will this happen in Massachusetts?  To understand this, you need to understand two other key concepts in the plan:  the CANS and the CSA.  The CANS is a tool, that allows the Behavioral Health providers to put the family at the center of the care plan, by focusing on their strengths and needs.  Pediatricians don’t do CANS- it is administered at the Behavioral Health Agency to which you have referred your patient.  With the CANS in hand, however, that agency is able to decide whether the child is “seriously emotionally disturbed” and qualifies for full “wraparound services”.

If they don’t, they may still benefit from either outpatient therapy or in-home therapy without wraparound services.  If they do qualify, however, a care coordinator will work with the family to develop an individual care plan (ICP) that addresses ALL of the family needs.  The care coordinator, working for one of 27 brand-new Community Service Agencies (CSA)  around the State, will convene a meeting that includes ALL of the significant forces in the child’s life, including mental health workers, school personnel, community workers, DCF and, quite probably, the primary care pediatrician.  The care coordinator’s job is to ensure that the family can maximize the effectiveness of these services, and help us to all work together for the benefit of the family.  The CSA is the glue that facilitates communication between the various parts of the system, which, as we all know, sometimes do not speak with each other.  In the end, this approach has the potential to create powerful synergies for some of our most difficult patients.

            Starting on 30 June, we all get to put the pieces of this system together.  What can pediatricians do to make sure that it works?  Here are a few suggestions:

  • Keep screening the children in your practice for behavioral health problems.  Our screening efforts are the engine that will make the system work.
  • Refer positive screens for evaluation, and learn the language of the CANS.  It is the common language for the development of the treatment plans in the new CBHI. 
  • Comment on the Individual Care Plan that is developed,
  • Know your  CSA and the be part of the team, so that you can support families as they work through the new system.

For all of us who have wrestled with Behavioral Health issues in our practices, the CBHI represents a chance to help.  The plan is complicated, it has a lot of acronyms and it risks becoming another impenetrable bureaucracy.  If we can keep families at the center, however, it will allow us to offer hope to families that have had little hope in the past.  That, as least, seems worth the risk.


For more information, try these websites:

1. Children’s Behavioral Health Initiative: www.mass.gov/masshealth/childbehavioralhealth

2. Rosie D:  Reforming the Mental Health System in Massachusetts http://rosied.org/

3.  Mass Behavioral Health Partnership Online: http://www.masspartnership.com/

4.  Rosie D. and Me: A pediatrician reflects on the mental health of children and the systems that are trying to help them. http://olddockeller.blogspot.com/

Wednesday, June 10, 2009

PCCs and Rosie D: A meeting in Springfield

This morning, I had the privilege of talking to a group of 25 doctors (mostly pediatricians), nurse practitioners and clinical administrators in West Springfield about the new services about to be rolled out in the CBHI.  I may post the slides at some point, but they are long and many and it would take a while to do so;  perhaps I will post them after I do the Eastern Massachusetts version of this talk (as noted in the "upcoming events" part of the blog).  The session went really well;  these folks have a good sense of the clinical load with which they are dealing, the resources currently available in their area and the difficulty of engaging a system in change.  They were simultaneously engaged in understanding the system and thinking creatively about how to overcome the barriers likely to pop up in such a system, while voicing their concerns over lack of resources and waiting lists within the current system (or non-system of care) of care.  A few highlights:
  • Acronym overload:  The folks at the Massachusetts Behavioral Health Partnership put together a great packet of information about the program as it seems to be evolving and included a glossary of selected CBHI terms.  33 of them, starting with APRN and ending with SOC.  (The Free Dictionary lists 123 possibilities for that one).  There is a lot of detail in this proposed system, and it will be confusing to many.  I tried to focus on 4 key bits of jargon: SED,  CANS, CSA,  and "wraparound" in an effort to keep it simple.
  • Capacity underload:  People get the model, people understood the sorts of patients that we are trying to manage, but it was very clear that they thought that we were opening Pandora's box, that the number of children eligible for services would quickly overload the new CSAs.  Perhaps, but we have to start somewhere....
  • Desire for change: This was a group of people like me, who have been banging their heads against the "wall" of mental health services for many years.   They are eager to engage the new system, but wary of get getting their hopes up.

All of this means that we need to continue to engage primary care providers in the next phase of the CBHI, if we are ever going to address the access issues raised in the Rosie D. lawsuit.  Hope to see some of you at the next session in Waltham.

Tuesday, June 9, 2009

The Industry Strikes Back: Counter-Testimony on H.3546 from Another Point of View

Last week, several of us testified in favor of H. 3546, a bill to induce the private sector to pay for a piece of the care coordination necessary to provide effective mental health services for children and adolescents in Massachusetts.  No one provided oral testimony opposing the bill;  Blue Cross and Blue Shield of Massachusetts, however, did submit written testimony opposing the bill.  It makes for fascinating reading- here is a summary:
1)  "Blue Cross and Blue Shield already factors in collateral activity in developing reimbursement rates for providers".  Really?  That is not what the folks in my billing office tell me;  we get to charge only for time in the room with the patients;  time on the phone doesn't count in figuring the level of services.  To which encounter do we attach the collateral service, when it happens with the patient out of the room?  In any event, it seldom happens, which implies that their "factored rates" are not enough to make it happen.
2)  "Analyzing the cost impact of coverage for collateral services is difficult because of the significant uncertainty about how they would be provided and billed".  I agree, but I have great faith that the insurers will develop appropriate hoops for us all to jump through.  The service is necessary;  smart people can figure out to prevent fraud.
3)  "Further information is needed to truly understand the efficacy and cost of providing and reimbursing for collateral services... Creating a mandate when so little information is available is unwise..."  This service is required of public players, and they have found it useful.  Surely, the private sector can provide the same level of service, and perhaps generate data on its efficacy. 
The Massachusetts Association of Health Plans offered similar critiques; the ultimate refutation lies in the product that the current system produces.  We all knew that screening for behavioral health problems was a good thing, and many thought that it should be part of the primary care package; it did not catch on in Massachusetts until primary care providers got reimbursed for it.  Similarly, if you only pay us for face time with patients, that will be mostly what you get.  This bill will help, and if it leads to broader discussions of the need for collateral services in other areas, so be it.  In the end, our patients will all benefit.

Monday, June 8, 2009

Slides are Ready: Talking Change and CBHI in Springfield

On Wednesday, I will be giving a talk sponsored by the Massachusetts Behavioral Health Partnership on the role of the the Primary Care physician in the new and improved Children's Behavioral Health Initiative, which makes its big debut on July 1.  Preparing the talk has been interesting;  I'm not part of the planning team, but I have been trying to pay pretty close attention to the process and to understand the various pieces of the puzzle.  The folks from MassHealth are very interested in the details of the program;  I am much more interested in the details of my patients and we are both very interested in not saying anything that is factually incorrect or that will either get people's hopes up too much.  This new system is going to take a while to shake down and folks have to be ready for that.  Anyway, putting the talk together has crystalized a few thoughts in my thinking on the impact of the Rosie D. case:
  • The plan for the system is designed to address many of the concerns we have had in the management of children and adolescents with serious emotional disturbances as community-based care has replaced psychiatric hospitals as the standard of care.
  • We are making a massive change in a really complicated system.  We can predict a few of the places where it is likely to get messy,  like identification, communication, coordination, and appropriate level of service
  • The new systems will provide better service, but they will be new.  Like a new car, it will take us a while to get used to the configuration of the controls.
  • The most important thing we can do in the process is listen to the patients.  That will keep us on track.
I took stuff from a lot of different sources-  we will see how it goes. (Only cartoon in the talk is given below)   Hope to see you at one of them.

Sunday, June 7, 2009

Organizing for America Health Care Kickoff (Updated)

I did attend one of the Health Care Organizing Kickoff meetings, as I described live in the text outlined below.  I mostly did it because I wanted to see who was going to be there and what they were thinking about.  What I didn't expect was or the experience to crystalize my thinking about single payor.

So, this is my attempt to blog in realtime on iPhone, in a dining room in the west side of ProvIdence with 4 people in and out of the workforce (bank workers, a doctor from Kenya, a transplant from Chicago) We are listening to the Obama video, in which he really focuses on the three principles of his reform-controlling cost, picking your own doctor and getting everyone covered. They are planning a 27 June 'community' event. And he is aiming for the grassroots.

Ideas included a health fair, maybe along with a farmer's market. People really want to do something. It is hard to type on this thing
Some observations:
People really didn't like the mandate (the Massachusetts plan), and many have had experiences with gaps in coverage, and people spoke of the need to make insurance universally available and accessible the folks on the margins. People liked the idea of Medicare for everyone. There was much concern about how much this was all going to cost and the notion of health care related bankrupcies was a bit scary. People are not sure what they want, but they want it to be easy.
In the end, our group decided to meet again next week, to work on using the website to call people and focus their thinking on health care  and to work toward some sort of "volunteer" event in conjunction with one of the Farmer's Market's that seem so ubiquitous these days in Providence and Pawtucket.

But my epiphany came with the realization that our whole system of payment  is based on the notion that there are people out there willing to take a sucker bet.  See, insurance is a bet:  One party (call them people) fronts money to the other party (call them insurance companies) and says "I will bet you that the cost of my (and/or my families) health care will be more than this".  If "people" are correct, the "insurance company" spends more money on the "people" than the stake that we gave them and we get health care.  Why do I call this a "sucker bet"?  Because, ultimately, and in non-random ways, we ALL get sick.  So why do the insurance companies take the bets?  Because they are VERY good at manipulating those odds, through co-pays, prior authorizations, exclusions and the like.  ALL of the things that we are proposing to do to the system under the HELP committee's proposal  or Baucus' proposal from Finance are attempts to retain that relationship at the core, the bet in which Insurers need us to either be healthy or to be off of their plan to maximize profit.  They change the rules of engagement to move toward the goals set by the President, that healthcare control cost, allow patients choice of provider and be as universally accessible as possible.  Once we change the rules, however, the insurance companies will work really hard to find ways around the new rules.  They are good at it, as they should be.  As the core, insurance is a sucker bet that will only be taken by folks who we allow to find ways around the rules.  Gambling is certainly one way of spreading risk around.  It just doesn't work so well when the risk is a certainty.  We have done this with many services in the past, including schools, fire departments and police departments.

Wait, you say, fire departments?  Yep, used to be a subscription and competition and all of that.  Led to fights over the sweet deals, fights on the streets and less than universal coverage.  Sound familiar?

Single payor is a way of reducing a lot of that confusion:  it allows you to rationalize the payment scheme, eliminate the fighting on the streets, save money AND control costs, something that the "invisible hand" of the marketplace does poorly for things with inelastic demand.  Single payor would allow doctors to be doctors, rather than entrepreneurs.  SIngle payor would mean that patients don't have so many arguments with the multiple payers in figuring out what to do.  When you look at it that way, it is a no brainer.

The folks in my group liked this argument.  If only I knew how to make it politically feasible.

Getting back to the larger question, why is the Obama campaign, now the soul of the Democratic Party, doing this grassroots thing?  Nice article discussing that in yesterday's Times- check it out here.

Saturday, June 6, 2009

From the CBHI: Guess I'll need to change my slides

This is very good news.
MassHealth Gets Approval for 5 More New Behavioral Health Services for Youths Under 21  
The federal Medicaid agency known as the Centers for Medicare and Medicaid Services (CMS), recently gave its approval of the long-awaited State Plan Amendment necessary for MassHealth to pay for five additional behavioral health services.  This follows the agency's previous approval of the new service "Intensive Care Coordination" last December, bringing the total number of approved new behavioral health services to six.  Yesterday's approval now gives MassHealth the green light to provide Family Training and Support (“Family-Partners”), Mobile Crisis Intervention, In-Home Behavioral Services, Therapeutic Mentoring Services, and In Home Therapy Services for eligible MassHealth-enrolled children and youths under age 21.  Currently, Crisis Stabilization remains the only service in need of CMS approval.  
Last October, at CMS' request, MassHealth withdrew its written responses to the federal agency's formal requests for additional information.  The withdrawal stopped the CMS 90-day review process, allowing more time for additional discussion and preventing a potential denial of the entire State Plan Amendment (SPA).  For the next five months, a number of productive conversations and exchanges took place between CMS and MassHealth.  When MassHealth formally resubmitted material in March, CMS requested that MassHealth remove Crisis Stabilization from the State Plan Amendment and re-submit it as a separate SPA. This was to allow continued discussion between CMS and MassHealth regarding outstanding issues on this services.   A new SPA containing the Crisis Stabilization service was recently submitted to CMS.  A decision should be reached by CMS prior to the service's planned start date on December 1, 2009.  We will continue to keep you updated.

Children's Behavioral Health Initiative

email us: CBHI@state.ma.us 


Friday, June 5, 2009

Back in the Field: What Do Primary Care Providers Want?

June in a primary care office is an interesting time;  graduating high school seniors come to see their doctor for the last time before they go to college.   Pre-kindergardeners are looking for their last batch of shots before starting off in school.  This year, we add a bit of the H1N1 swine flu into the mix.  And then, we have the children with behavioral, developmental or psychiatric problems, coming to the doctor for advice on what to do next-  "My med isn't working" or "I changed my mind and want to try medications" or "What do I need to do to see a neuropsychologist?".  The last is a real problem out our way;  the nearest pediatric neuropsychologist is 20 miles away, and appointments are quite difficult.  Yesterday was a slow day:  19 patients (4 "no-shows"), but we had our share of issues.  They raised in my mind some thoughts about the ideal system:
  • A 10 year child with known mental illness, on three meds, currently doing well in school, whose mother is wondering how long to continue this "cocktail" of medication, which were finally finalized in 3 years ago.  "Does he need to stay on the these forever?", she wondered,"When is it safe to change them?"  She finds it hard to discuss these things with psychiatrist in the context of the 15 minute medication check;  she feels guilty that her fabulous child requires this much medication; she feels safer talking about it with me.
But I have no notes from the therapist or psychiatrist on which to base my thoughts, and I have no means of getting my thoughts to the psychiatrist other than through the mother.  Is this the best we can do?
  • A 5 year old child with a normal PEDS but a heaping helpful of energy and a strong desire for attention, who has been adopted by an older couple who sort of understand my reluctance to medicate children before they start kindergarten.  I've tried FST, but the family was unhappy with that in practice.  I will try to refer them to MCPAP, in the hope of getting them hooked up with the CBHI.  
The family is not terribly interested in behavioral approaches or family support;  they want me to use medications in a way in which I am uncomfortable.  Am I wrong to be uncomfortable? Am I hiding behind my algorithms? Or is the system just too darn complicated?

  • An 18 year old overweight boy with autism, on no meds at present, working with his mother to figure out what comes next.  He is pretty well connected with the system, and his mother has opted to give him legal status as an adult.
His life, more or less, is dependent on the votes of the legislature as they realign funds to meet the budget crisis.  How will we arrange his transition of care?

Back in the flow of the community, I perceive that things haven't changed too much.  The CSAs are coming, the system is still complicated and I find that still, the most valuable thing that I can do with patients is to listen.  In June, we sometimes have time to do that.  It is how we learn.

As I was writing this reflection, Matt Noyes of the Children's Mental Health Campaign sent me some things about the Health Plans' testimony at the Mental Health and Substance Abuse Committee hearing last week.  Expect a posting on this soon.

Thursday, June 4, 2009

What about the Mental Health in Private Sector?

One of the things that I have been learning about public policy over the past 2 years (the duration of my almost concluded Physician Advocacy Fellowship) is that the passage of a law or the implementation of a regulation is but the first step along the road to change.  The other is that there are many things in the air at once, and it is important to pay attention to all of them.  Lately, I have been focused on the upcoming CSA deployment in the CBHI, the implementation of Yolanda's Law and the passage of legislation focusing on reimbursement for collateral contacts.  But aren't we also in the midst of rolling out the Mental Health Parity Laws, both State and Federal?  Turns out we are, and the Children's Mental Health Campaign has been right on top of that, even if I haven't been watch that aspect of this complex dance as well as I might have done.

While we have been working on the Medicaid system, and on finishing off the Omnibus Mental Health Bill, the Department of Mental Health has been trying to clarify what the new Mental Health Parity Laws mean in real life.  They issued one memorandum to the commercial insurers in March,  in which they clarified who was covered;  they need to issue a memorandum discussing what sort of services should be covered under the parity law.

The big sticking point  is the level of intermediate services that are covered.  Both Medicaid and the Private payers cover the easy stuff:  When I want once a week meetings with a therapist for a child with mild mental illness, I can get that through the outpatient department.  When I want hospitalization, I can get it if I jump through enough medical necessity hoops.  What about all of the other services that we can get for children on Medicaid (but not on the privates), like the ICC, the Home-based behavioral and psychotherapy sessions, the Parent Partners and the like?  I once had an insurance company (or rather a nice person at an insurance company)  tell me that they would rather pay for the EMH and Hospitalization than cover in-home therapy for a kid who was making weekly trips to the psych ER.  Wouldn't budge, even though it would save them money.  So, doesn't it make sense that Mental Health Parity means that the private sector should cover the same services as are covered by Massachusetts Medicaid program?

That is the message that we in the  Children's Mental Health Campaign want to send to the Division of Insurance and the Department of Mental Health:  parity means more that covering hospitalization.  Private insurance should cover a WIDE RANGE of Intermediate Services, including :
  • Intensive Care Coordination
  • Community Based Acute Treatment
  • Family Consultation
  • Day Treatment
  • Crisis Stabilization
  • Family Stabilization
and many other things.  Basically, private insurance should cover everything that the public sector is providing under the CBHI.  Intermediate Care is the key to creating a mental health system that actually achieve parity with the physical health system.

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