Tag: Healthcare reform

Healthcare Reform: Where does mental health fit in?

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I was all set to write an article on various health disorders and their cost. Then I got frustrated. You see, I started reading the original articles upon which the news/opinion articles I was using as reference were based. I found very rapidly that the figures being used in the articles were comparing different things…some of the totals included reporting by consumers of care; some of the totals included services under multiple diagnoses; adding the totals together summed to much more than we spend on all health care all told. I wonder  how much of this misuse of data is occurring during our ongoing national discussion of health care reform. Apples and oranges are not the same and mixing data can result in sloppy conclusions.

On September 10, 2009, the New York Times published an Op-Ed piece by Michael Pollan in which he discusses the costs of health care in the U.S. Big Food vs. Big Insurance discusses the report of the Centers for Disease Control that chronic illnesses account for 70% of all U.S. deaths. The medical bills of those with chronic diseases result in 75% of the health care spending in the U.S. Pollan argues that some of those chronic diseases…obesity, diabetes, cardiovascular disease…are at least partially the result of America’s terrible diet and overeating. Just helping U.S. residents eat better could result in a dramatic reduction in the costs of health care.

Pollan’s position received some confirmation from a podcast of Science Friday on August 28, 2009. How Cooking Made Us Human focused on the hypothesis that humans evolved effectively and developed larger brains because we started cooking our food. Cooking begins breaking food down before it is eaten, so it is easier to digest. Raw food is harder for the body to digest, so one does not get as much nutritional benefit from the food eaten. The result for human evolution was that we were able to take better advantage of the food we ate by cooking it.

The corollary of this hyothesis is that highly processed foods are a big contributor to obesity because they are too easy to digest. The more processed the food, the easier it is for our bodies to use the caloric content of the food. The result is that those whose diets consist largely of processed foods are also heavier. Raw foods are likely good for some who want to lose weight because the body has to work harder to digest them and does not get all the caloric benefit from the food. One can eat more, feel more full, but consume fewer calories.

Pollan’s point that a change in one aspect of our lives could have huge impact on health care spending got me to wondering…is there a mental health issue that is analogous to food/eating related disorders like obesity, diabetes and heart disease?

According to Open Minds On-Line News for September 14, 2009, mental disorders jumped from fifth place among health expenditures in 1996 to third place in 2006 increasing from $35.2 billion to $57.5 billion. The number of people who sought treatment for mental conditions went from 19.3 billion in 1996 to 36.2 billion people in 2006. While the dollars expended per person for behavioral health care are many fewer than for heart conditions ($1591 vs. $3964), perhaps there is a way for behavioral health providers to dramatically reduce costs of care by addressing a single problem.

According to the U.S. Surgeon General, approximately 20% of the U.S. population experience some sort of mental health disorder in any given year. The best estimate is that 16.4% of the population experience some sort of anxiety disorder ranging from Simple Phobia to Post Traumatic Stress Disorder. A full 82% of those who experience a behavioral health disorder suffer from some sort of anxiety disorder.

Is it possible that education on stress reduction, prevention programs aimed at inoculating the U.S. population against anxiety and early treatment of anxiety disorders might decrease the cost of treating the disorders that do emerge? I have heard public health specialists argue that public education and prevention are the only way we will ever get our health care spending under control. I also have read that there is not yet compelling data to demonstrate that preventive care reduces costs at all.  Perhaps we should just focus our attention on the behavioral aspects of the chronic physical diseases? Or maybe behavioral health providers can work in both arenas and assist in dramatically diminishing the costs of health care across the board.

What do you think about this issue? Where should psychologists, psychiatrists, social workers, mental health counselors, community mental health centers and community behavioral organizations focus their energy? Where will our energies be most effectively spent?

Please enter your comments by clicking on the title of this article and typing your comment into the box below.

Prevention & Self-Care: Essential to good health

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A couple of weeks ago I wrote about my experience of incapacitating back pain while on vacation. Today, I woke up feeling great. My visit to my chiropractor and massage therapist was unusually positive; my muscles were not in spasm and my spinal alignment was pretty good. It is clear that the things I have been doing are finally working.

What I did not write about two weeks ago were the efforts I had been making to manage my back and neck pain prior to its explosion while I was trying to have a good time. Two and a half years ago I fell from my bike and separated my shoulder. Six months after that, the neck pain caused by the fall spurred me to visit the chiropractor. For the last 18 months I have had massage and chiropractic adjustment every two weeks, on average. Our goal is a monthly maintenance schedule to prevent my poor spine from causing the kind of discomfort I experienced last month. Because I was not making the progress I had hoped for and was starting to get depressed about it, two months ago I started yoga classes and two weeks ago I added a Pilates class.

I have made efforts toward fitness for my entire adult life. I have eaten a mostly vegetarian diet since 2005. I have maintained my weight at a healthy level and my BMI (body mass index) is 21.3 (18.5 – 24.9 is considered normal). I have a couple of familial predispositions to heart disease, so I try to keep all the other risk factors down. For the last ten years, I have bicycled pretty regularly, and for most of my life I have been involved in physically active endeavors ranging from dance and aerobics classes to vigorous gardening. Familial tendencies toward depression and other mental health issues, along with my training as a psychologist, have also pressed me toward regular maintenance. My copy of David D. Burns, M.D.’s  Feeling Good, the New Mood Therapy and The Feeling Good Handbook are never far away.

The more I think about the health of my nearly 59 year old body, the clearer it is to me that my focus as an individual and our focus as a culture needs to be on good self-care and prevention of illness. For those who work in preventive medicine, my realization would be followed by a big “DUH…of course.” For most of the rest of us ordinary humans, it is easy to give lip service to this notion, but really acting upon it is another matter.

Newspaper reports about the effects of recession on preventive health care abound. Some insurance plans do not cover preventive care, and when money is tight people do not spend on a mammogram or colonoscopy. Those who have lost a job and their health insurance along with it may seek care for acute illnesses, but prevention and care of chronic illnesses often go by the wayside, sometimes resulting in expensive emergency room visits and hospital admissions.

The Agency for Healthcare Research and Quality (AHRQ) of the U.S. Department of Health and Human Services provides a Guide to Clinical Preventive Services. Screening and Counseling are the two forms that most preventive efforts take. Frequently, education about the disease and self-care for prevention are part of the Counseling. Unfortunately, for many of the illnesses listed there is insufficient evidence to determine the effectiveness of Screening or Counseling in preventing the disorder. The dates on most of these conclusions make it clear to me that it is time for a significant research push in this area; but, Evidence Based Practice will be the topic for another day.

One arena in which prevention has solid research basis and support of the medical community is cardiovascular health. “The American Heart Association believes that basic preventive health care services should be an integral part of an equitable, comprehensive health care plan, accessible to all.” Learning the risk factors of cardiovascular disease and intervening to diminish those factors is a sure way to decrease the likelihood of heart attack in your future. As the AHA indicates, “These are the risk factors we can modify, treat or control:

  • tobacco smoke
  • high blood cholesterol
  • high blood pressure
  • physical inactivity
  • obesity and overweight
  • diabetes mellitus.”

I am not a person who is happy to take a passive role in my life. Sometimes I wind up in that position because of a variety of factors, but the result is never a happy Kathy. I have always been proactive and forward-looking, trying to be prepared for eventualities before they occur. Sometimes I have missed the mark by looking too far ahead, but in the case of health it is never too soon to start taking steps to prolong good health.

Dr. Andrew Weil has long been a favorite of my family. His blending of Eastern and Western ideas in integrative medicine has an intuitive appeal for me. The notion, put forward in his book Healthy Aging, of avoiding many debilitating illnesses by proper diet and exercise and living a long healthy life with a rapid decline at the end seems a no-brainer to me. My health insurance won’t reimburse me for it. Traditional U.S. medicine won’t advocate it until there is significant research supporting it; but I find this active, involved focus on my health much more appealing than passively taking the medicine the doctor orders.

What is your role in your health? Do you see a place for behavioral health providers in prevention and general health care? How should we proceed to make ours a healthier country and each of us healthier individuals?

Please chime in! Let me know what you think.

U.S. Healthcare…Privilege, Poverty and Pain

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This is my second day back in the office after vacation. Yesterday and this morning were filled with catching up. That will take most of the rest of the week to complete. I decided to share an experience and some reflections before I get too removed from them.

While on vacation, my back went out. I have had chronic back issues since I was a young woman…maybe even since I was a child. In January 2007, I fell from my bicycle and separated my shoulder. Since October 2007, I have regularly visited a chiropractor to manage the neck pain that has become a focus since that fall. My neck and back have become chronic problems with intensity of pain varying depending upon multiple factors.

Vacation was a bicycling getaway in the Florida panhandle. The cottage we stayed at in Apalachicola had a bed that did not agree with my back. After two nights of wrong mattress and two days of riding, my lower back went into major spasm. I spent the third day of vacation searching for a massage therapist and traveling 100 miles to purchase a mattress topper to ease the pain. Everyone with whom we dealt was extremely kind and concerned, even when they were not able to help.

I did manage to relieve the discomfort somewhat and rode for three more days after we moved on to Monticello. Some correction to my bike position and change in pedaling technique also helped. You will notice that I did not try to see a physician and I did not go to an emergency room. Dealing with out-of-network services for a chronic rather than emergent condition felt too costly to justify. Fortunately, I found a massage therapist and could afford to pay her.

On our final day, we visited Thomasville, GA. As we drove into town, we passed a demonstration opposing health care reform. Signs indicated that “they” are going to increase our taxes to pay for someone else’s healthcare, and  “we” cannot afford to pay for the poor to have insurance. The participants were overwhelmingly white skinned, well-dressed individuals.

Today I managed to get to my own chiropractor and massage therapist. My insurance only pays the chiropractor $15 per visit; they do not cover massage therapy at all. Because these services keep me functioning, I choose to pay for them and am fortunate to be able to do so. But during this summer when Congress is working hard to come up with a plan to reform our healthcare system so more people can afford to receive care, I find myself wondering how we will succeed.

1. From amidst my pain, my thinking about how to resolve my discomfort was minimal and ineffectual. Soaking in the tub did not take care of the problem. Over the counter medications did not relieve the pain. Without my husband to find resources for me, I might still be in that tub. I think about the emotionally ill individual who has no one to advocate for them…mired in their pain and confusion without treatment.

2. Even with good, costly health insurance, the community in which I was located did not have resources for which my insurance would pay. If I were not privileged and educated and benefiting from adequate income, I would have been unable to pay for the resources we did locate. There are no local mental health services at all. I think of those who live in small town America and cannot travel to the resources of larger communities, as well as those who live in cities who cannot afford to access those resources.

3. I know very few health care providers or training programs or modern treatment procedures that were not assisted by government funds. Health research and hospitals and medical school and even graduate school in psychology cost too much for most of us to pay without government grants or loans. Even those of us who can afford to pay are dramatically benefited by government funding.

4. We are a kind and concerned people.

5. We are selfish and protective of our money, our privilege and our position.

6. There are no easy solutions to healthcare reform. It is going to cost all of us. The only question is how much it will cost and how we will pay for it, and whether the mechanisms are different from how we pay now. It is unconscionable that access to basic healthcare is not guaranteed to everyone who lives in the U.S.

This is all my opinion…for what it is worth. And what do you think? Please make your comments by clicking on the title of this article and entering your thoughts in the box at the bottom of the page.

Death and EMRs: Disruptive events?

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The deaths of the past week have set me to thinking. The mother of a friend passed away early in the week followed by the wife of a family friend. Then, news of the death of cultural icon, Michael Jackson, was everywhere.

I come from a family and culture (New Orleans-based) where death is an intrinsic part of life. It very much affects those who are touched most directly by the loss, but it is also integrated into day-to-day life in such a fashion that life moves on with barely a ripple. The deceased is celebrated and mourned in one or multiple events ranging from wake to jazz funeral. Burial in above-ground graves and mausoleums (the water table in New Orleans is very high) caps off the events, and the cemeteries are daily reminders of the short-term nature of life. As with everything else in New Orleans, after death there is a party, but there is real disruption only for those immediately touched by the death. Life goes on.

I married into a family that shares the more traditional views of death held by most of American culture. It is not to be talked about too openly, lest it be invited to approach. And, as for most people in our culture, death is definitely considered to be a disruptive event, dislocating those related to the deceased from the ordinary course of life for an extended period of time. In fact, the disruption is frequently so severe that it is no surprise to those around the survivors that they are forever changed.

The term disruptive technology was introduced by Clayton M. Christensen in 1995 and together with his modification disruptive innovation has become a catch-phrase for technological change that is so radical that it dramatically alters the course of events that follow. If you read any articles about technology, you will come across the terms.

On the way to an event yesterday, we were listening to a podcast of The Week in Technology (TWIT) in which Twitter was discussed as a disruptive technology…disruptive to the field of journalism and to our whole way of communicating and thinking about news events. The techno-nerds who are the mainstay of TWIT are convinced that the immediacy of communication enabled by Twitter is and will continue to radically alter the way in which we receive information, likely becoming the jumping off point for even newer innovations in the realm of communication and information sharing.

I find myself wondering if Electronic Medical Records (EMRs) will not become the same kind of disruptive technology for our current healthcare system. Since EMRs have been around  for a while now, many would argue that they will certainly change healthcare, but do not reach the level of disruptive technology. But when I think about many of our customers in the behavioral health community and the radical changes to their organizations that will be required to move to EMRs and to use them in a meaningful way, I can imagine few more disruptive events.

Some would say that managed care had the potential to be just as disruptive…it certainly changed the way in which private mental health practices have conducted themselves over the last twenty years…but it did not intrinsically change the way in which the provider interacts with the recipient of healthcare services. The consumer may be seen less frequently and for a shorter total length of treatment, the managed care organization may refuse to pay for certain types of care (which the patient can then purchase with their own dollars), but the provider still sees the patient, assesses the problem at hand and provides treatment.

EMRs have the potential for changing that sequence of events. If used in a “meaningful” way, if decision support tools and treatment protocols that are based on scientifically assessed methods (evidence-based treatment) are incorporated into the EMR products and utilized by providers at the point of care in the way envisioned by the framers of HITECH, we will have a new healthcare system….or maybe not.

What do you think? Will widespread adoption of EMR systems be a disruptive innovation for healthcare? Do behavioral health EMRs have the potential to be disruptive technology for the mental health community?

Please add your comment by clicking on the title of this article and typing your thoughts in the comment box at the bottom of the page.

Healthcare Reform: What part will you play?

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One of the largest challenges for the small employer (like us) is providing health insurance coverage for our employees. While wages are our largest single expense, we spend an additional 11% of that amount to purchase health insurance for our employees. The costs of that coverage have increased every year that we have offered it. As a basis of comparison, we have increased our product prices at something closer to five year intervals (2001 and 2006). Those of you who work in the private sector may have implemented price increases in your organizations more frequently than our once in five years, but those in the public sector have found your “fees” (dollars earned per unit of service provided) diminish significantly. No matter where you are in this equation, you have seen the cost of healthcare—physical and mental health—skyrocket in the course of your working life.

President Obama is working to pass Healthcare Reform that will diminish the ongoing increases in the cost of healthcare. On Monday, he announced and the NY Times reported that the major players in the healthcare arena, doctors (American Medical Association), hospitals (American Hospital Association), drug makers (Pharmaceutical Research and Manufacturers Association) and insurance companies (America’s Health Insurance Plans), along with the  Service Employees International Union, had voluntarily agreed to reduce costs of health care by 1.5% per year over the next 10 years. The dollar amount of this reduction is a whopping $2 trillion…a figure so large that it is almost meaningless to us lesser mortals.

While no one gave any details, it is clear that this huge public relations event was intended to place these players in a good and cooperative light. It is also clear that they offered voluntary reductions hoping to avoid mandates. They did not offer to remove opposition to a public health insurance plan modeled after Medicare from which Americans could buy insurance rather than from a private insurer.

In all of the articles I read on this announcement, mental health / behavioral health was not mentioned at all. While the National Council reports  that Americans with serious mental illnesses die an average of 25 years sooner than other Americans with three-fifths of those individuals dying from preventable, chronic diseases like asthma, diabetes, and heart disease, the seriously mentally ill appear to be nonexistent in the Obama administration’s world. It would seem that people who utilize such a significant quantity of healthcare resources might be an important group to consider.

Paul Krugman, the Nobel prize winning economist who writes for the NY Times, sees Monday’s announcements as unlikely to guarantee anything…but as an extremely hopeful event. It is the first time these major industry groups have said that they are willing to participate in cooperative endeavors to reform our healthcare system. Maybe something positive will come out of the efforts this time.

How do you imagine your organization will be impacted by healthcare reform? What kind of transformation would be most likely to help your provider organization? What variety of restructuring will help your clients? And what changes will help you as a consumer of healthcare services? What kind of reform would you like to see?

Please add your comments to this discussion by clicking on the title of this article and entering your thoughts in the box at the bottom of the article.