Statement from The Kennedy Family

Hyannisport, August 26, 2009

"Edward M. Kennedy -- the husband, father, grandfather, brother and uncle we loved so deeply -- died late Tuesday night at home in Hyannis Port.

"We've lost the irreplaceable center of our family and joyous light in our lives, but the inspiration of his faith, optimism, and perseverance will live on in our hearts forever.

"We thank everyone who gave him care and support over this last year, and everyone who stood with him for so many years in his tireless march for progress toward justice, fairness and opportunity for all.

"He loved this country and devoted his life to serving it.

"He always believed that our best days were still ahead, but it's hard to imagine any of them without him."

Hard to add anything to this. All of those dedicated to improving the health care system are in mourning. Of course, we need to keep doing the next thing, in his memory.

MCPAP Needs Our Help (and our Stories)

Adapted from a recent e-mail blast:

The various MCPAP programs need help to negotiate with the medical insurers who provide behavioral health and medical coverage to your patients. In the State’s FY 2010 budget, the MCPAP received a 20% cut in funding with the State’s intention of having the private insurers make up this shortfall. Presently all of the money supporting MCPAP comes fully from state dollars. This is in spite of the fact that more than half of the calls and families evaluated by MCPAP have private insurance with a behavioral health benefit. It will be difficult for any program to take a 20% cut in support without decreasing services.

MCPAP is asking our involved primary care clinicians to write a brief letter describing the value of MCPAP to your practice and the patients you treat. If appropriate, you could note your understanding of the limited access that you have to mental health services in the community. MCPAP will use these letters in our negotiations with the private insurers to both demonstrate the value of our state-wide service as well as to show the important (albeit invisible) role we play in the insurer’s delivery system, filling some of the gaps that we know are there.

If you are willing to write a letter, you use the MCPAP “Tell Us Your Story” link here, which may result in your comments being published on the MCPAP website . We are hoping to receive supporting letters by early September.

From the Maternal and Child Health Bureau

PAPER DELINEATES BENEFITS OF AN INTEGRATED APPROACH TO SUPPORT CHILDREN'S EMOTIONAL WELL-BEING

Strategies to Support the Integration of Mental Health into Pediatric Primary Care provides an overview of research advances and policy trends that support integration of mental health into primary care and explores strategies that can be employed by primary care health professionals, with support of health plans, to achieve coordinated and integrated mental health care in the pediatric primary care setting. The issue paper was published by the National Institute for Health Care Management with support from the Maternal and Child Health Bureau. Topics include the prevalence of and risk and protective factors for children's mental health problems; the current state of mental health in pediatric primary care, including the relationships between primary care and mental health services; public and private sector financing of mental health services for children and the implications for integrative approaches; federal, organizational, and foundation initiatives supporting integrative care; and considerations and strategies for health professionals and health plans to improve the delivery of mental health care in pediatric primary care.

Conclusions and selected resources on children's mental health care are provided. The paper is available at http://nihcm.org/pdf/PediatricMH-FINAL.pdf.

A thought from a reader

It is nice to know that folks are still reading this blog; being in the office, packing up my office and furnishing an apartment in DC has cut into my blogging time.

Hi David,

I was just catching up on your blog and saw that you are leaving for DC in less than 2 weeks. Last time I talked to you, you were awaiting a "call" on whether you were keeping your blog. So what happened with that?

I am really glad you are commenting on CBHI. I am realizing more and more that there is very little critical observation and even less advocacy (except for rates). At times like these, I really miss Walter!

At any rate, I am wondering about the blog and want to wish you well on your sojourn in DC. Please stay in touch!!! We wade in on national health policy stuff from time to time (as you might guess).

Best,

***********

-------------------

In case you were wondering, authors LOVE it when someone asks them to keep writing. This sort of e-mail just makes me want to get out there and write more. Thanks, **********. This means a lot. Let me try to answer as best I can.

1) I will try to keep this blog both alive and focused on the Children's Mental Health Reform process on which we have spent so much time and energy. That may be tricky, as I will no longer have direct contact with my patients, who have always been my best source of information about the CBHI, and the mental health system in general. But I will try.

2) Over the next few months, I will be undergoing a training process in Washington, organized through the Institute of Medicine, that will give me access to many of the folks setting the policies that drive what we do. I mostly can't talk about that, especially on an open blog. By January 1, I will be an aide in a Congressional or Senatorial office. At that point, I may or may not be able to blog at all. So, stay tuned.

But what of the CBHI in the lazy days of summer? I actually had two folks from the Worcester CSA (their new name escapes me at present) join me in discussing the CBHI process with our Housestaff at UMass Medical Center last week. They told us that they have enrolled the first 90 or so families in the program and that they are working on the second hundred now, doing CANS, hiring staff, convening meetings (like the one I couldn't make last week) and the like. They were surprise at how few of their referrals are coming from pediatricians and other primary care providers. I wasn't. Traditionally, there has been so little communication between primary care and behavioral health providers that I would have been surprised if they were contacting the CSA themselves. Most of us give parents a list of counselors and agencies and have them get to it. So the CSA would likely not know that the primary care doc had sent the patient.

So it is churning, and movement is happening. If I can make it to the next community meeting in Webster, I will have much more to say on that.

Anyone else got any stories? Put them in a comment, send them in an e-mail. It is out there, percolating now. Look at CBHI on Google News here.

On a personal note, I still can't believe that in 8 days I'll be on my way to Washington. It is simply too cool to be real.

Pictures from a Town Hall Meeting.

I went to the Town Hall (literally) in Warwick on Wednesday night to try to hear Representative Langevin speak on the prospects of health reform, and instead found a wild group of LaRouchites (with Obama as Hitler posters), "Government can't do anything" folks, Democrats, Union supporters, medical students and the odd pediatrician standing around, outside the Hall, trying to convince the the media of their importance. It was an interesting scene; I met few there who had not yet already made up their minds and many who enjoyed shouting and chanting. As a singer, I sort of get that- their is value in the human cameraderie that goes along with a good chant. In this case, however, it made it difficult to engage in a meaningful discussion with the folks who had serious doubts about the legislation, which is why I was there. But I tried.

I would say that the folks who were present broke down

into three groups. First were the supporters of reform; largely professionals, Obama supporters and union folk. Tended to be younger, tended to be less loud- these folks were often single-payor supporters, and were very much in favor of the inclusion of the public plan in the mix of things to come out of this process. In talking to them, I was concerned that they were too focused on the public plan; for many, the loss of the public plan would mean that we had failed in our effort, even if more people were covered and the insurance industry is dragged into a process other than ruthless competition to fund the care that people need. You all have probably guessed that I think that this process is essential; the "free" market as currently structured is likely to oscillate and collapse unless we are able to realign the structure in which it operates. Kind of like the stock market, except this bubble really does kill people directly. So "our side" needs to convince its own people that 3/4 of a loaf is an acceptable outcome.

Second were the ideologues, the folks who think that the government is simultaneously incompetent and unable to accomplish anything AND evil, conspiratorial and able to focus in and ruin their lives in a really personal way. It is interesting to talk to them; the arguments tend to be circular and to focus back on personal attributes of the one that they are trying to convince. I was asked over and over again, "Have you read the bill?" Well, yes, but, unless you are an attorney, reading the bill doesn't really tell you very much. The language is there, but the meaning of the language is steeped in prior legislation, numerous Court decisions and the policies and procedures of the Department of Health and Human Services. We are all, in many ways, dependent on our colleagues in the legal professions to tell us what this bloody thing means, and sometimes they don't even know until it is passed. Smart people think that this thing will get more people covered, support the move to quality improvement and allow me to take care of children without worrying about their coverage all of the time- that is actually good enough for me. The bill is hundreds of pages long (double spaced, though), and is worth a look through.

The biggie for me is that it extends EPSDT to children on the Children's Medical Security Plan- that is a huge boon to families of children with special needs and I am absolutely for it.

Third were the critics with ideas, and there were a lot of them. People who think that things need to change, but that this bill (the House Bill being the only one on the table at the present time), is not good enough. I spoke with one IT guy who was worried that the system would be too permeated with politics- he favored removing this from the political process. Another person was a hospice worker, concerned that they would mess up the regulation of the transition from treatment to end of life care. A couple with seven kids gets their health care through a Christian health cooperative- they were concerned that they wouldn't be able to continue in this form of insurance that worked so well for them. These are folks that we can talk to- they may never support the reform, but they won't blow up the country to keep it from happening.

The one thing that was clear that evening was that people on all sides of this debate care deeply about how this thing happens- inside the room, the session went on for several hours, and we stood out there without a speaker, talking and yelling and arguing and waving signs and engaging in the political process that makes us who we are: Americans. My side has not yet closed the deal on this thing, but neither has the opposition run it off of the cliff. It is time, though, for all of us to weigh in and figure out which side we are on.

A Busy Day: I missed my chance to see the Team in Action

Got this from the CBHI today:

August 18, 2009
Over 1,000 Families Enrolled in ICC Services!
On June 30th, Community Service Agencies (CSAs), the organizations that deliver Intensive Care Coordination and Family Support and Training, began providing services to children, youth and their families. Since that time, the MassHealth Health Plans have reported over 1,000 families are in the beginning stages of working with Intensive Care Coordination services. During the beginning “engagement” phase of this service, families work with Care Coordinators and Family Partners to complete a “strengths and needs” discovery and start building their child’s ICC Team. In the experience of Wraparound programs nationally, as well as CFFC and MHSPY in Massachusetts, some number of families will decide during this process that ICC is not for their family. CBHI will begin to have data in September on the number of families that enroll beyond the engagement phase. Intensive Care Coordination (ICC) is a care-coordination service for children and youths with serious emotional disturbance (SED). Children, teens and young people most likely to benefit from ICC services may include: those with complex needs involving many providers or state agencies; families of children or youth who have frequent behavioral health crises; and children or youth in families that have been “difficult to engage” in other services.

I know this to be true- as I mentioned last week, I got invited to one of those meetings myself. During the day. When I had patients. So I couldn't go.
Mental health figured prominently into today's patients: a young man with ADHD and an untreated substance abuse problem heading off to college; we had a long talk about weed and apathy and the possibilities of drinking and drugs in teh big city (I won't say which one!). Another youth, repeating 9th grade, whose ADHD is unresponsive to medication because it doesn't work ("I don't feel any different") or because he doesn't take it very often (last Rx was in December, although he claims to be on the stuff). Neither of them is seeing a therapist; both have one parent in MA and one in CT, making it tricky to sort out which mental health system to access. These kids are hard to manage, and I truly look forward to having a CSA with whom to work.

Back from the Mountains: The Cost of Children's Health

I saw patients today, 9 physicals with negative behavioral health screens, a bunch of kids with acute medical problems, a few behavioral/mental health follow-ups and no contact with the CBHI. It is really odd to think that I will be leaving the practice in a mere 14 days, and that I only have 6 more days of clinical pediatrics before I descend into the maelstrom of Washington politics.

One of the reasons that children are often absent from the discussion of health reform is that, in general, child health is a small percentage of the cost of health care (some colleagues refer to the cost of "child health" as a rounding area when compared to the cost of care for the elderly). My AAP News today, however, suggested that we should be looking at this in a different way. According to a recent study by AHRQ, $98.8 billion was spent on children's medical care in 2006. Please note that this is in the context of $2 - $3 trillion of total expenditure on health care, so that is a mere 5% of the healthcare pie. 5 conditions account for 30 % of that spending, and mental health costs led the way in terms of expected outlay. As the same time, it turns out that the insurers have managed to turn this one into a massive cost shifting to the consumers. When one looks at the percentage of that cost that is paid out of pocket by parents, 21% of the bills are shouldered by parents, in the context of a system that most would consider to be woefully inadequate, compared to 11 % of the bills in the case of infectious disease. These data confirm what we already knew- that a substantial part of the problem of access to health care for children is access to mental health services, and that the system is designed to restrict access as a means of cost control. Clearly, for children, this message needs to be heard in the discussion on Capital Hill.