I recently read the article "Some Claim ACO Status Without Truly Changing," about how some provider organizations are asserting they've "always been an ACO."  This did give me a déjà vu moment.

I feel like I'm in a time warp, caught somewhere around 1990. Remember that year?  Margaret Thatcher resigned, Manuel Noreiga turned himself in, Jim Henson died, Driving Miss Daisy won best picture… And that's also about the time that executives of provider service organizations got the idea that they could be managed care organizations and manage the financial risk of health care for a population. Most often those executives told me they had "always been responsible for a fixed budget."

Now the strategic theory behind provider organizations managing health care financing is a sound one on many levels. From the organization’s perspective, controlling all of the funds for a population is one way to protect their strategic market position. From a health care policy perspective, it makes sense to have clinical professionals making the decisions about rationing health care resources.

But, if the ACOs of the future are going to succeed, executives of provider organizations need to realize that it is not business as usual. That is the reason so many managed care initiatives owned and operated by provider organizations failed. They believed there was no difference.

What I heard at the time was the oft-repeated phrase: "If only we had all the money, everything would be fine" (still, of course, a popular phases these days too). But, since the clinical professionals who run most provider organizations are trained to think on a case-by-case basis (instead of a population basis), they are not well-suited for managing population-based health funding. And at that time, executives of many provider organizations quickly learned how tough it is to make a margin managing a pool of funds.   Some of the them learned the hard way (financially speaking).

Now before you send me a message about either the evils of rationing (some entity has to do it) or my negativity about the executive management of provider organizations, I would like to point out that I think that financing of health care services based on some risk formula (capitation, case rates, etc.) is generally a good policy decision. But, to be successful, executive teams of provider organizations need to become "data-driven" in their analysis and decision making.   

I think there is nothing significantly different from ACOs of today and the managed care programs of two decades ago (though many of program architects disagree with that statement). But, without some significant change in management tools and organizational culture, management teams of provider organizations are going to be as successful (as a group) at managing ACOs in the future as they have been at running managed care programs in the past.

A few weeks ago, I read a Wall Street Journal  article, "Law Prompts Some Health Plans To Cut Mental-Health Benefits," which summarized a Kaiser Family Foundation survey (Employer Health Benefits 2010 Annual Survey) on the effects of the behavioral health parity law on employer-sponsored health plans  – this article shouldn't have come as a surprise to those who are familiar with the past data. Of employers with over 50 employees, 69% didn't change their benefits at all. Of the 31% that did change their benefits, 66% changed their behavioral health benefit limits to equal physical health benefits; 16% increased their use of managed care; and 5% eliminated behavioral health benefits overall. That last 5% was, of course, the focus of The Wall Street Journal article.  

The article's authors did cite the Congressional Budget Office estimate that parity would increase premiums for group health insurance by an average of 0.4%, and the work by Steve Melek, a behavioral health  expert for the actuarial firm Milliman Inc., which showed that not providing benefits for mental health and addiction leads to higher overall health care costs. The article also referred to the fact that these plans would have to add back this coverage if the health care reform legislation moves ahead; the law requires that health plans offered through the soon-to-be-launched health insurance exchanges meet certain minimum level of benefits.

But the line that really got a rise out of me was the very last of the article; it referred to how the Screen Actors Guild (SAG) was going to help their members now that they had eliminated all their behavioral health benefits (both services and pharmaceuticals).  The article stated that their plan "will begin working with its members to help refer them to community-treatment options […]." I don't know what mythical free sources of mental health and addiction treatment services and pharmaceuticals the CEO of SAG was referring to, but I certainly haven't come across any. Our team at OPEN MINDS works with a wide range provider organizations who see the 'flood' of Americans who are uninsured and (in this case) underinsured looking for free services. Provider organization budgets for free services are very small—certainly not enough to cover the U.S. population currently uninsured and underinsured for the treatment of mental illnesses and addictions.

In the future, I'm hoping that policymakers will drop their references to this land of "happily ever after," wherein everyone can magically receive free behavioral health services. Policy decisions only work when you make them for the real world. 

Like many Americans, I was first stunned and then unsettled by the shootings that took place last week in Tucson. Since then, we’ve heard lots of debate about Jared Lee Loughner's motivations. Partisan media hyperbole? Targets on an election map?

Most recently, there has been a chorus of pundits singing about the ills of the mental health system. Michael J. Fitzpatrick, Executive Director of the National Alliance on Mental Illness, said, “The plain truth is that America's mental healthcare system is horribly broken and horribly underfunded. And across the nation, budget cuts continue to eviscerate community mental health programs that reach out to vulnerable individuals and put them on a path to recovery.”

But more surprisingly, have been the statements of key Republicans:

• Republican advisor Mike Murphy said on the Bill Mahar Show on January 14, 2011, "I'd like to see a better linkage between the gun control stuff we have now and the crazy-filter. Because if you look at Virginia Tech and you look at this guy, it is too easy for mentally ill people to get guns; because there’s no mental screening anymore."
  
• Virginia Republican Senate candidate Jamie Radtke (and head of the Richmond Tea Party) told ABC’s Top Line that "instead of it being about the political part, it’s really about needing to get our arms around our health care, the mental health policy here."
  
• Representative Mike Rogers (R-MI) said, "What we have to do is intervene earlier in that cycle of violence when they have this kind of disability. . ."
  
• Newly-elected Representative Allen West (R-FL) said, "The shooter was a very disturbed individual and it appears there were so many warning signs that he was going to do something horrible.  We should be focusing on the mental health crisis in our country, not politics."

Well, I have a simple piece of advice: if we want to stop tragedies like this from happening again, we should not repeal health care reform. Two years ago, national legislation passed that (finally) guaranteed that most individuals with insurance will have coverage for assessment and treatment of mental illness. The health care reform legislation builds on that non-discrimination parity legislation and assures that most Americans will have some form of health coverage that includes coverage of mental health conditions.

Earmarked funding for community mental health services will not solve the problem. We need to end fundamental discrimination against people with mental illnesses, and ensure that they have consistent access to the health care services that they need.

Americans are not of one mind about health care reform— a recent Gallup survey showed that 46% were in favor of repeal and 40% wanted to move forward with the law being enacted. (Interestingly, there were great differences in support of the law based on age – with the under 30 crowd clearly in support and the 50+ crowd favoring repeal.)

I can understand having qualms about some provisions of the health care reform law. If I were queen, I would have done things slightly differently. But, I am absolutely opposed to repeal. And what I don't see coming from the repeal advocates is a plan—for anything.

Our health care status quo isn't working for anyone—not for consumers, employers, governments, or anyone else. Last Thursday, the Congressional Budget Office concluded that between 2012 and 2021, repealing the law would increase the national debt by approximately $230 billion (more on that in a future blog post…). And so when I talk to the folks looking for repeal, my question for them is always: what's your plan?