“If the new federal law equalizing coverage for mental conditions with that for medical-surgical care works as hoped, there may no longer he a need for a public system to handle mental health in the long run,” says Michael Hogan, New York State’s mental health commissioner.
This was the headline and lead on the Wall Street Journal’s health blog April 16, 2010 story by Shirley Wang following my comments at a NYC mental health conference. (Sometimes you know there’s a reporter in the crowd, and sometimes you don’t.) In this case, however, I won’t claim “I was misquoted.” Rather, given our history and the road ahead, it’s a good time for serious thinking about the future.
The theme is not new. In 1993, in an earlier era of (anticipated) healthcare reform, a group of state mental health commissioners met with the mental health task force, chaired by Tipper Gore, of the Clinton health reform effort. We had much to talk about. The Clinton reform proposal was to recommend universal health coverage, with mental health parity. Surely part of the conversation had to consider the role of the state public mental health systems.
The commissioner’s group, meeting as an ad-hoc task force of the National Association of State Mental Health Program Directors, had already considered this issue. And so, when the question came: “If health reform includes universal coverage and full parity, are you willing to discuss folding state resources into the larger system?” we were prepared. And the answer was “Yes. We have lots to discuss…state responsibilities extend beyond healthcare, like forensic services and housing. These will need to continue. And we’ll need a careful transition. But we should not maintain state systems if the alternative is being part of the mainstream.”
Almost two decades later, the seemingly impossible future has been promised to the American people, with the combination of national healthcare reform, parity for both mental health and addiction treatment, and aggressive parity regulations that raise the bar on acceptable treatment. What can we expect in this new environment?
My crystal ball predicts two things about the future of separate public systems. It’s a paradox. First, in the next couple of years, little will appear to change. The combination of uncertainty, phased-in implementation of the federal legislation and the “boiled frog effect” will mean that little is changing – or rather that few changes are apparent. (The “boiled frog” dynamic is cited in Peter Senge’s Fifth Discipline: The Art and Practice of the Learning Organization, The story is that a frog placed in hot water will leap out. A frog in water that is slowly heated to boiling will not realize what is happening until it is too late. The dynamic, Senge argued, applies to human perceptions of complex change.)
The second prediction I am pretty certain about is that in 45 years distinct public mental health systems with state-operated and state-funded specialty services will no longer exist in anything like their current form.
Actually, I think the change will happen more quickly. But it’s been 45 years since Medicaid (and Medicare) were created, so it is a useful analogue. Recall that, when enacted, Medicaid had no specialty mental health benefit, and that state (and private) psychiatric hospitals (IMD’s) weren’t covered. And then consider how things have changed in the past four decades.
Acute care was moved to newly covered units in general hospitals, so that there are only a few thousand “state beds” still devoted to acute care in the entire country. Nursing homes were covered for intermediate care while state hospitals were not, so by the mid 1980’s several hundred thousand elderly patients (and some not so elderly – in an unfortunate lesson about the power of financial incentives) had been moved to nursing homes. By 1985, Gronfein had demonstrated that the (indirect) impact on mental health policy of the Medicaid program was already greater than the impact of the community mental health centers program. And that was before things really ramped up; you know the rest of the story. Medicaid benefits for community care (clinic, case management, rehabilitation) were in place. Special services like Assertive Community Treatment were covered. “Medicaid it” became a cry of cash-strapped budget offices and an army of consultants. Today Medicaid’s funding levels, policy influence, and – in many states – impact on mental health care, is greater than that of the state mental health agency (if one still exists).
And the changes since 1965 were not explicitly called for. Now, parity is the law, and the administration proposes rules for parity that do not allow different approaches for managing overall health benefits. So think about it again. Will we need a separate mental health system in the future?
The long term, I admit, is all speculation. The question before us now is what mental health managers, providers and advocates should be seeking, and acting on, as we move forward. We know what consumers will be seeking. The evidence is before us, in data showing that behavioral issues are the number one cause of pediatric visits and also that the treated prevalence of depression doubled after the introduction of the SSRI’s – although most care in general medical settings is not up to recommended standards. People want care in the mainstream, for complex reasons that no doubt include stigma, convenience and coverage.
I believe our challenge is at the heart of healthcare reform. It is also evident in the statistics above. While people want care in the mainstream, the general health sector, without our help, is incapable of reliably delivering good behavioral healthcare. We see this across the lifespan in care for depression (a prevalent disorder that is reliably diagnosed and usually well treated by specialists). In the general medical sector, depression is often undiagnosed and when diagnosed it is usually undertreated – from peri- and post-natal depression to adolescence to middle age to late life chronic illness. (Keep in mind that depression is usually simpler to diagnose and treat than other disorders.) The research and demonstration programs yield clear results. With a mental health “depression specialist” on the team (not across town, not in another agency, not available via referral, but on the floor – along with screening, treatment protocols and measurement) good care can be reliably delivered.
Our mission, in the next years, is clear. We must lead to achieve integration of care, everywhere. We also have to integrate medical care into our specialty settings, because without it our clients will never get decent medical care, and the rates of premature death will not improve.
We also must work to integrate mental health competencies into all clinical general medical settings – because emerging standards of care will demand it. We have to demand and assist health plans to pay attention to behavioral health in a fashion that goes beyond inadequate measures (did discharged psych patients make a single timely follow-up visit?…puhleez) to fully integrated care expectations and outcomes. At the national level, we need leadership to increase access to appropriate psychotherapies, recognizing that we have over-corrected to a dominance of medication treatment.
I am of the belief that the path ahead will see a few entrepreneurial leaders embrace the challenge of achieving true integration at every level from policy to plan to practice. These entrepreneurs will also succeed in business, because the game will come to them. Most of us will stumble along the road that we are on. For many, it will turn out to be a dead end, because someone got to the integration mandate ahead of us. And in some circumstances, we will have no leadership, and no mission except cost control – leading to a kind of deinstitutionalization revisited. In the next round of state budget cuts, in fact, we may see some early evidence of this unfortunate trend.
There are certainly other challenges that will continue to require state, federal and local mental health leadership. Key supports (e.g. housing, employment) are outside of health care. Special responsibilities like forensics are in statute. More must be done to support prevention/early intervention services that now have the force of evidence behind them. But the topic of the day, and the biggest area of federal reform, is in the area mentioned in our name – health.
How do the events of the past 18 months affect this commentary? Very little, in my view. But we see signs of accelerating change. Almost all the new service models unleashed by the Accountable Care Act – from Medicaid Health Homes to Accountable Care Organizations to patient-centered Medical Homes – cannot succeed without integrating behavioral and general medical care. The theme of “integration” is popping up everywhere. Yet the mainstream is not prepared. They need our help. On almost every crucial test – for example people discharged from an emergency room after self harm, or people who commit suicide after seeing a primary care provider – the mainstream still gets it right only about half the time.
What’s your vision of the road ahead? Does it depend on specialty state agency leadership? Does it depend on protected status for particular providers? Or do you have a business plan for success, in an integrated health AND behavioral health environment?
Michael Hogan is the New York State Commissioner of Mental Health. His experience in mental health administration and research is unparalleled and includes leadership roles with the President’s New Freedom Commission on Mental Health, the Joint Commission, the National Institute of Mental Health’s National Advisory Mental Health Council, and the National Association of State Mental Health Program Directors. He has coauthored a book and several national reports, written more than 50 journal articles and book chapters, and received numerous awards for his service and leadership.
Special Thanks: This article was originally published in National Council Magazine, 2010; revised February 2012. Mental Health News wishes to thank Linda Rosenberg, MSW, President and CEO of the National Council for Community Behavioral Healthcare for granting us permission to reprint this article.