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.

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.

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.
 
 

CBHI
Children's Behavioral Health Initiative
www.mass.gov/masshealth/childbehavioralhealth
email us: CBHI@state.ma.us 

">

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.

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.

Resident's Day at the State House: Trainees Educating the Legislator

Each year, our Academy organizes RFDASH:  "Residents and Fellows Day at the State House" to bring to the legislators in the great State of Massachusetts, and today is that day.  We have great trainees in Massachusetts and they have once again organized a great experience in the State House.  Today, we are talking about 3 bills:

• S.366.   An Act to Regulate the Use of Off Highway and Recreation Vehicles:  Kind of a no brainer: ATVs are dangerous to children, we need to figure out how keep kids from being hurt by them.  There is some opposition, so we need to point out the need for this legislation from a public health standpoint.
• H.3586 and S.757.  An Act for the Coordination of Children's Mental Health Care Services:  You folks know all about this one:  if you don't, check out last week's blog entries.  One Senator seemed pretty certain that this would pass without too much trouble this year, especially because the fiscal analysis that was completed last July showed such a minimal budgetary impact.
• H.3453 and S.859.  An Act Establishing the Massachusetts Childhood Vaccines Program and the Massachusetts Immunization Registry.   This last one is brilliant;  we are bringing the private sector into the immunization system so that we can once again be a universal vaccine state.  The interesting thing in discussing this bill is that the opposition to the legislation in at least one Representative's office is from the folks that don't want want to immunize their children.  The bill is about paying for vaccines for folks that want them and keeping track of the folks who have been immunized, largely to prevent over-immunization (currently, if we can't find your records, we have to assume you to be unimmunized).  All of the options for rejection of vaccines remain intact, although I confess that I don't understand people who reject one of the few bits of medicine that we understand really well.

What is nice about working for the Academy is how the causes for which we fight are usually on behalf of children and not simply working for better reimbursement.  It was great to see 60 residents and fellows add their names unto the fight.

Intensively Coordinating Care: A Few Kinks in the Process

So, as H.3546 rolls through the House with nary a glitch,  I wanted to talk a bit about the role of care coordination in the process of children's mental health care and in particular in the "Rosie D." remedy plan.  Throughout the lawsuit and the negotiations on the remedy, the plaintiffs have spoken of the difficulty of engaging the various systems (e.g. DCF workers, DYS staff, DMH managers, school personnel, pediatricians, mental health workers, psychiatrists and youth workers at the Boys Club, for example) and of the need to convene team meetings to allow the family to have all of the members of their team pulling together to benefit the child and family.  In the RFR, as part of Intensive Care Coordination, the Care Coordinators  will have

"Regular contact by  with the family, youth (where appropriate) and other relevant, persons in the youth’s life (collaterals),  Facilitation of CPT meetings  [and] Face-to-face contact with the youth and family, as determined by the youth and family and members of the CPT"

I have speculated before that this will be hard to do;  I have been trying to attend as many multi-agency team meetings as possible in the run-up to July 1 to see how this is going to work.

Last week, a patient of mine with serious emotional disturbance had such a meeting scheduled, and my care coordinator and I tried to attend.  Multiple e-mails were exchanged to assure that we wouldn't forget the meeting, as it was scheduled on the day after Memorial Day.  We were there at the appointed hour; the parents were there as well.  The agency, on the other hand, had cancelled the meeting, as the lead person was on vacation.  Assurances were given that we were all called;  neither my care coordinator or the parents can find any evidence that this happened.  Did all four of us, with e-mail, cell-phones and home answering machines miss the message?  Did it get caught on a SPAM filter?  Or was it never sent?  We don't know.  We do know that two professionals and two parents spent 2.5 hours going to a meeting in a distant location that didn't happen.

Please note that I did not name the agency involved;  this is not meant to be about them, or us.  

To their credit, a superb worker familiar with my patient's family met with us informally for 30 minutes and useful information was exchanged.  Not a full team meeting, but a piece of one.  Still, multiply this by a factor of 10,000 children with SED;  to paraphrase Apollo 13: "Boston, we may have a problem here".    So, if this isn't about an agency or a patient, what is it about?  This is a plea to all parties that, as we design a system as comprehensive and multimodal as the one that we are planning, we need to invest in a communication system that crosses lines that we are not used to crossing.  Otherwise, this thing doesn't have a chance.

It will be an adventure.