OPEN MINDS on Blogger | Market intelligence for health and human service executives

Are ACOs the Managed Care Déjà vu?

2011-01-31T14:06:00.000-05:00

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.

The Mythical Land of Free Behavioral Health Care

2011-01-25T15:43:00.000-05:00

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.

Want to Stop Future Tragedies Like Tucson & Virginia Tech? Don’t Repeal Health Care Reform

2011-01-17T11:28:00.000-05:00

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.

America is Divided on Health Care Reform – So Where is the Alternative Plan?

2011-01-11T11:28:00.002-05:00

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?

Is Shared Value Really the Next Big Idea for Business?

2010-12-28T13:44:00.000-05:00

I'm a big fan of Michael Porter, but his latest piece, "The Big Idea: Creating Shared Value," left me a bit flat. The premise of the article is that our capitalist system is currently “under siege,” with the public blaming business for social, economic, and environmental problems. In order to legitimize business in the public’s eyes, Mr. Porter and his coauthor, Mark Kramer, propose that corporations shouldn't just focus on profits– they need to create "shared value," which they define as: "policies and operating practices that enhance the competitiveness of a company while simultaneously advancing the economic and social conditions in the communities in which it operates. Shared value creation focuses on identifying and expanding the connections between societal and economic progress."

The authors go on to say that the idea of corporations creating "shared value" will start to blur the lines between for-profit and non-profit entities. And while I understand their point, I don’t think that this "shared value" concept is the big idea that is going to revitalize capitalism – for a few reasons…

#1. "Shared value" is already an innate concept in organizations where the management lives where they work. If you live in the community where your company operates, you are always concerned about advancing the economic and social conditions surrounding you. The problem arises when there is no connection to the community. Whether you’re dealing with absentee landlords of real estate or corporate entities, it's hard to care about what you never see and people you'll never meet.

#2. The issue of “shared value” isn't what is going to blur the lines between for-profit and non-profit organizations. That distinction is strictly an issue of repatriation of profits—do profits go to shareholders or are they reinvested? There are many mercenary non-profit organizations that have as little "shared value" as their for-profit counterparts.

#3. We will never have "shared value" in publicly-traded companies. Executives of publicly-traded companies won't be in the positions long if they don't maximize quarterly earnings—a goal that can never be consistent with advancing "economic and social conditions in the communities in which it operates."

In theory, I am a huge supporter of the "shared value" concept that Mr. Porter and Mr. Kramer forward. But in practice, I think we can all recognize that it will take more to "legitimize" business.

Be Careful of What You Ask For...

2010-12-15T11:53:00.000-05:00

Like many of you, on Monday I saw the news that a federal district judge in Virginia ruled that the insurance mandate in the health care reform bill exceeds the authority granted to congress under the Commerce Clause of the Constitution. (It apparently is Constitutional to mandate that employers provide health insurance, but not individuals – a distinction I don't quite get.)

But that is not the purpose of this missive. To all of my colleagues who are applauding the death of the individual mandate, I would like to give a quick remedial course in health care financing. In order for our health system to eliminate preexisting condition clauses and exclusionary enrollment in health plans, the current mandate for individuals to buy health insurance is a necessity. It is financially impossible to have one without the other; if there were no mandate, everyone would simply wait until they were ill to get health insurance – something akin to allowing an individual to buy homeowners insurance the day after they have a fire.

So what is the answer?

#1. Fight the Virginia Court decision to the Supreme Court (likely), and restore the individual health insurance purchase mandate within health care reform.

#2. Accept the Virginia Court decision and allow the return of preexisting condition clauses and exclusionary enrollment in health plans. I think this is poor (and penny-wise, pound-foolish) policy choice. We have many Americans who forced into bankruptcy paying for treatment for devastating acute and chronic health conditions.

#3. Accept the Virginia Court decision and have the federal government provide health insurance for all uninsured persons, which would keep the ban on preexisting condition exclusions in health plans.

For those of us trying to find the “middle ground” in health care reform, I'd like to point out that ruling that individual purchase mandates are unconstitutional is likely to spur an increase in federally-financed coverage. I'm not sure this is the outcome that many of those organizations financing the anti-health care reform lawsuits will want. But, as they say, be careful what you ask for. . .

Hospital Trends for 2011 – Great Insights For All Executive Teams

2010-12-08T09:49:00.000-05:00

I just read a great piece in Becker's Hospital Review, “10 Key Trends for Hospitals in 2011,” which focused on hospital subject matter experts’ predictions for the new year. Their observations are relevant not only if you’re in the acute care sector of the field, but also serve as useful guideposts for any organization in the health care field.

The ‘top ten’ trends this group is expecting include:

1. Lower reimbursements
2. Recovery audit contractors (RACs) gather momentum
3. More uncompensated care
4. Political gridlock
5. Uncertain fate of healthcare reform
6. Anticipated ACO rules may open the floodgates
7. Greater focus on experimentation
8. States will further cut Medicaid spending
9. Healthcare IT payments start
10. More hospital consolidation likely

I think these will prove to be trends that all management teams will need to factor into their planning scenarios. So make sure that your team – and your plan – is ready for the new year.

More Evidence of the Prevention Opportunity

2010-11-29T22:19:00.000-05:00

I’ve written in the past about the need for specialist health care organizations (such as behavioral health organizations) to reposition themselves in an era of changing technology, science, and financing. There are many possible directions for repositioning – from primary care for individuals with chronic conditions; focused disease management programs for consumers with multiple chronic diseases and complex social support needs; and program to address unnecessary use of high-cost acute care interventions.

Now comes yet another study on the cost savings opportunities of prevention efforts in two areas – high blood pressure and diabetes. The study authors concluded that reducing the prevalence of diabetes and high blood pressure by five percent would save the nation about $9 billion a year in the short term. In addition, conditions related to those health problems would also be reduced, which would increase the savings to about $24.7 billion a year in the medium term.

The study was conducted using 2003-2005 data from the Medical Expenditure Panel Survey. Study results were released on-line on November 18, and are scheduled to be published in the January print issue of the American Journal of Public Health.

This is data that can be the foundation for designing (and marketing) prevention programs. For more on the evolving wellness and prevention market, check out these recent articles by our team:

Market Opportunity in Prevention Programs: Reform Creates New Market Niche for Prevention (available to premium OPEN MINDS Circle members)
New Science Changing The 'Perceived Value' of Prevention & Early Intervention (available to all OPEN MINDS Circle members)
Mental Illness & Addiction Prevention & Treatment Critical to U.S. Health Reform (available to premium OPEN MINDS Circle members)
UnitedHealth Group Launches Diabetes Prevention & Control Alliance With Partners Walgreens & YMCA of the USA (available to premium OPEN MINDS Circle members)
J&J to Grow New Wellness & Prevention Business as Part of Consumer Division (available to premium OPEN MINDS Circle members)

When it comes to health care, your choice in today’s election is a simple one…

2010-11-02T17:37:00.000-04:00

On October 11th, John Boehner (R-Ohio), the current House Minority Leader—and the presumptive Speaker of the House in the 112th Congress—warned that we should not expect funding to implement health care reform if the Republicans become the majority in Congress – “They’re going to need money from us to hire those 22,000 federal employees we think it’s going to take to run this monstrosity. And I’ll just tell you, they’re not going to get a dime from us.”

Representative Boehner went on to acknowledge that an all out repeal of the health care law is unlikely, as President Obama will still hold veto power from the White House. But even if an outright repeal isn’t possible, Republicans will still have the ability to hold up funding for many aspects of the reform legislation through the annual budget process. If Republicans take control of the House (as most polls indicate is a very likely scenario), Boehner stated that it will be the Republicans “job to do everything we can to keep it from being implemented, to keep it from moving ahead.”

So, as I see it, the choice in this election regarding health care is a clear one. Flawed or not, do you want health care reform? The bill has many great features—elimination of preexisting conditions clauses and recission, access to minimum coverage for the poorest Americans, etc. But, I think we all recognize that it also comes with a range of problems to be fixed.

Which leaves one question to think about: If the Republicans are in the majority, what is their alternative proposal?

Will Consumers Take the Red Pill?

2010-10-25T10:29:00.000-04:00

I’ve been keeping up with the exciting new neuroscience developments on the cause (and hopefully treatment) of Alzheimer’s disease. One of the articles that I recently read was from CNET, “The Red Pill of Alzheimer's: Would You Take It?” The most recent development is that scientists are now able to go beyond your genetic biomarkers for the genetic risks associated with developing Alzheimer's disease – they can now identify whether you will have a slow progression of the disease or a disease that will “spread like wildfire.” The scientific discussion in the article is interesting, but the part that I found most fascinating was the question that this research poses: If this genetic test was available, would you take it? Would you take the “red pill” and see how far the rabbit hole goes?

If the “red pill” analogy is lost on you, a quick refresher: The red pill/blue pill concept was popularized in the 1999 movie The Matrix. The movie’s premise is that an artificial reality is advanced enough that it is indistinguishable from reality. And in the movie’s beginning, the protagonist (the always-contemplative Keanu Reeves) is presented with a choice—take the red pill, which will free him from “the matrix” and bring him into the real world, or the blue pill, which will allow him to stay contentedly unaware in the artificially constructed reality. Borrowing from the movie, the terms “blue pill” and “red pill” have become a metaphor for the choice between facing the world’s difficult realities and maintain the blissful ignorance of illusion.

So, back to Alzheimer’s disease; the real issue is whether or not consumers will avail themselves of these genetic tests. Alzheimer’s disease is really only the beginning—I’m sure that more advanced testing with genetic markers will soon be available for other conditions as well. The ramifications of these tests will take us far beyond medical decisions and treatment options; it is the individual psychological and larger societal implications that will have a monumental impact. Will consumers yearn to know so that they can better manipulate the outcome, choosing to live with the knowledge of their future demise? Or, will they trade in the time that they could gain to prepare for their fate for the bliss of temporary ignorance?

I think the answer to that question lies in American’s unique “where there’s a will, there’s a way” attitude. Consumers maintain a belief that, if they have early knowledge and they have access, there will be some treatment, some technology, some breakthrough that will enable them to change the outcome of the disease. And then the problem will become how consumers deal with the outcome once they have chosen to take the “red pill.”

Is Medicaid Really "Intergenerational Welfare?"

2010-10-18T11:08:00.000-04:00

In a recent speech, Kentucky Republican Senate Candidate Rand Paul said that Medicaid is “intergenerational welfare.” His stated rationale was that coverage has spread beyond those “truly in need” and citing the fact that 800,000 people out of Kentucky’s approximately 4.314 million citizens (18.5%) were on Medicaid. Given Kentucky’s Medicaid eligibility requirement—$13,671 in annual household income for family of 4 (62% of the federal poverty level)—I would say that has more to do with the income distribution in Kentucky.

I find Dr. Rand’s comments a bit hypocritical. This is coming from a candidate who is an ophthalmologist (an ophthalmologist who invented his own board certification, no less) and has 50% of his income coming from Medicaid and Medicare. This is the candidate who said in an interview on October 3, 2010 that he would cut Medicare benefits and raise the retirement age for Social Security in order to keep the full Bush-era tax cuts. So while depending on your perspective, I suppose you could consider this to be intergenerational welfare; I would maintain that it is, in fact, intergenerational war.

Choose Wisely...

2010-10-13T15:26:00.006-04:00

I’ve been a bit perplexed by this election season. I’ve decided we’re stuck in a real-life version of the 1989 film classic, Indiana Jones and the Last Crusade. You remember the one—the globe-trotting, action-packed search for the Holy Grail. I’m reminded of those prophetic words near the end of the film, “...choose wisely, for while the true Grail will bring you life, the false Grail will take it from you...”

These would be good words for voters to heed on November 2nd. Unfortunately, we’re caught between a false set of choices due to the political messaging that we’re bombarded with via every type of media on a 24-hour basis.

The Republican messaging, with its recent “Tea Party” flavor, is generally “All government is bad.”
The Holy Grail – Eliminate government and let the free market rein.

The Democratic messaging, with its recent panic attack at the loss of the public popularity contest, is “Save government. It’s best for the little guy.”
The Holy Grail – Let’s keep our government operations on track.

I think the Republican Party is at its most disingenuous these days when compared to the past two decades, using those poor “Tea Party” chumps (most of whom are on Social Security and Medicare) to try to prevent government from curbing the worst of the free market abuses (I’m a free market person – and I can tell you that the ethical among us want protection from all of the unethical business entities).

I think the Democratic Party seems to be populated by fearful sycophants. They’re afraid to be the party of ‘good government’ (which is what we need) because introducing a accountability and good business practices would cause consternation among their traditional supporters.

My advice to voters: Choose wisely. Look for candidates who believe in good government – government that provides reasonable protections (regarding health, land use, safety, economics, etc.) to us all – government that is willing to apply standards, accountability, and good business practices. The candidates are out there in both parties, Republican and Democrat. But we need to turn off the campaign advertising and look beyond the party-line messaging. If you take the time to explore each candidate’s positions and background, you should be able to choose wisely.

The Current State of U.S. Unemployment & Its Implications for People with Cognitive Disabilities

2010-10-08T15:15:00.001-04:00

I've had a hard time putting the current unemployment data into context based on my own experiences – at OPEN MINDS, we've been on a hiring frenzy…and having trouble getting responses to our ads. Then, one Sunday morning a couple months ago I was watching Laura Tyson in an interview on ABC's This Week with Christiane Amanpour, and I had a flash of revelation. Ms. Tyson, former Chair of the President's Council of Economic Advisers during the Clinton Administration, said that "unemployment for those with college educations is now 4.5 percent." She went on to cite Bureau of Labor Statistics data that for those with less than a high school diploma, the seasonally adjusted unemployment rate was 13.8 percent during July. For those with a high school diploma but no college, the rate was 10.1 percent.

After thinking about that data, I have a new take on the unemployment situation. We have a structural unemployment problem, which is how labor economists refer to a mismatch between the skills of the people who of are out of work and the skills needed for the jobs that are available. And what this really boils down to is an education problem. A fundamental part of the long-term solution to our high unemployment rates is to improve our education system at every level – not only improving the graduation rates from high school and college, but also increasing the academic rigor of those programs. While it is certainly a valid point that "not everyone should go to college," given this employment situation, we also need to think of improvements to non-college technical/vocational training programs. Those training programs need to be relevant in the current context of a global economy and focused on areas with growth-potential that can provide a continuous living wage.

Diving deeper into the nationwide unemployment statistics and the prominence of the education attainment-aspect of the numbers led me to wonder what the implications of this situation would be for individuals with cognitive and mental disabilities. While assistive technologies are increasingly available to facilitate completion of advanced degrees by individuals with physical disabilities, disabilities that interfere with the thought processes are more punitive. In an economic environment where advanced degrees and related skill sets directly correlate to economic well being, the challenge of independently maintaining economic viability is becoming more and more insurmountable for these individuals.

I thought the best summary of the situation was in an article by Steven Pearlstein, The Bleak Truth About Unemployment. Mr. Pearlstein notes: "Somewhere between the rantings of the Republican right, which is peddling the nonsense that excessive government spending is to blame for high unemployment, and the Democratic left, which clings to the false hope that another helping of fiscal stimulus is all that is needed to get millions of Americans permanently back to work, is this stubborn reality: The loss of 8 million jobs reflects problems that are largely structural, not cyclical, which means they won't be brought back by fiddling with a magic dial in Washington that controls how much the government spends."

As Americans are pushed to develop a better-trained and more highly-educated workforce, the employment space for individuals with cognitive and mental disabilities will get smaller and smaller – leaving a population that will struggle to find a viable place in the fast-paced global market economy that we are heading towards.

Not One Solution in Sight...

2010-09-28T10:23:00.000-04:00

One of my greatest personal and professional peeves is the “constant critics.” These are the folks who constantly complain and critique what you do – but have no proposed solutions and rarely get things done themselves. My experience as the founder and executive of a small business is that while it is easy to play the role of critic, it is quite difficult to develop and implement real, workable solutions.

These days, I consider the Republican Party to be playing the role of the “constant critic” when it comes to health care. They had eight years when they controlled all branches of government, and did nothing. And now that someone else has taken a swing, all they have managed to do is complain. This “constant critic” position was perfectly captured in a piece by Grace-Marie Turner, “Putting the Brakes on Obamacare: How a Republican Congress Could Begin the Process of Repealing This Unpopular Law,” in the August 25, 2010 edition of The Wall Street Journal. Ms. Turner outlines “the six key strategies that a Republican Congress could employ to put on the brakes.” Her plans for health care reform? – Defund it, dismantle it, delay it, disapprove regulations, direct oversight and investigation, or delegate to the states.

Clever alliteration, but did you notice any solutions listed among those Republican “key strategies?”

Would Medicare Advantage Options Really Cost More?

2010-09-21T14:45:00.004-04:00

One of the big ‘war of words’ in health care is the issue of Medicare managed care – namely the Medicare Advantage program. President Obama and many Democrats want to scuttle the program because the cost of the managed care version of the Medicare program is purportedly 13% above the costs of the same beneficiaries in the fee-for-service version. Many consumers, and many Republicans, like the features and benefits and the voucher-like market orientation (respectively) of these plans.

The basic objections are captured quite succinctly by Ezra Klein in a piece in the The Washington Post, A private Medicare System Would be a Costlier Medicare System. He states, “They save money by limiting the generosity of the vouchers. Because the dirty little secret is that turning Medicare into a voucher program would actually make it cost much, much more. How do we know? Well, putting aside the fact that Medicare currently costs much less than private insurance, we actually have a private voucher program in Medicare as we speak. [...] But today, the market-based arm of the program costs more, not less, per beneficiary. Those fixed monthly payments to Advantage plans are, on average, 13 percent above fee-for-service Medicare costs.”

I think Medicare Advantage plans are an inevitable solution for the Medicare plan. The current fee-for-service system is an ungainly muddle of rules, with only the reduction in benefits (not politically feasible) and reduction in provider fees as its cost containment mechanisms. Even the health care reform initiative recognizes this through the creation of “accountable care organizations,” which are essentially provider-owned managed care plans. (And, it won’t take long for those provider-owned plans to “buy” managed care infrastructure from the current managed care programs.) Only this change in financing, moving us away from fee-for-service, permits the health care system to move beyond the current silos of reimbursement and allows for the rationing of services, which is an inevitability with, or without, health care reform.

That said, the failure that we currently have in the excessive rates mentioned by Mr. Klein is not a failure in program design, but rather a failure in contract negotiations and management. Medicare Advantage plans should not cost 13% more (or any more) than their fee-for-service alternatives. And, the medical loss ratio reporting requirements absolutely must be applied to Medicare Advantage plans to permit true transparency for consumers and a contract management tool for Medicare.

Two Tales of an Insurer

2010-09-14T16:40:00.005-04:00

Remember the story of the blind men and the elephant? In varying versions of the story, a group of blind men/men in the dark touch an elephant in an attempt to determine what it is; however, each one feels only one part of the creature, such as the tail or the leg. The men then compare notes and learn that all disagree on what they felt—the man who felt the tail thinks it is a rope, while the man who felt the leg believes it to be a pillar. The story originated in India and is used to demonstrate the relativity of truth.

Well, such is the reporting on the fate of one insurer, Assurant Health, in an era of health care reform. And, I’m certain that similar reports of facts, resulting distinctly different perspectives, will become more common as health care reform is implemented.

The facts: Assurant Health, a Milwaukee-based health insurance company, announced last month that it was laying off 130 employees in Milwaukee and Minneapolis.

The first perspective comes from “ObamaCare Has Failed,” an article by Grace-Marie Turner, Chief Executive Officer of the Galen Institute. Ms. Turner writes:

“The wheels are coming off ObamaCare even sooner than most had predicted. The American people are not being fooled by the sugar-coated sales campaign, jobs are being lost, health costs are rising, and the first program to be launched is a dud […]

Do liberals really believe that people aren't going to pay attention to double-digit premium increases that are coming, $575 billion coming out of Medicare to pay for massive new entitlement programs, the $500 billion in new taxes that are driving up health costs, the barrage of new regulations putting employers and the health sector in a straightjacket, and the despised individual mandate that will force Americans to purchase expensive, government-dictated health insurance?

Today’s news has direct evidence of jobs being lost as a result of ObamaCare. Assurant Health, a health insurer based in Milwaukee that specializes in individual and small group policies, announced that it is laying off 130 workers as of October 1. Assurant is a terrific company that was the first to sell a Health Savings Account policy and has continued to be responsive with innovative products to serve customer needs.

But new one-size-fits-all regulatory requirements are forcing insurers to slash personnel to meet new ‘administrative’ tests, rules that present real challenges to a company that focuses on direct customer service rather than selling policies thousands at a time. Assurant is highly adaptable and will survive, but many capable employees and their families can thank ObamaCare for losing their jobs.”

The second perspective comes from “As Reform Improves The Overall Market, Inefficient Insurers Could Take Hits,” by Jonathan Cohn, Senior Editor of The New Republic. Mr. Cohn writes:

“When Assurant Health, a Milwaukee-based health insurance company, announced this month it was laying off 130 employees in Milwaukee and Minneapolis, it blamed the health care overhaul for its struggles […]. The carrier is Assurant, which specializes in selling policies in the individual and small business markets […] – the place you find carriers that aggressively avoid people at risk of getting sick […]

The health law forces insurers to cover basic benefits […] And it limits the money they can spend on administrative overhead or broker commissions. Once fully implemented, reform will also prevent these carriers from avoiding people with pre-existing conditions. Make no mistake: These are all good things. They mean insurance is becoming more accessible, more comprehensive and more efficient.

Alas, that may […] be bad news for Assurant. If the company's name sounds familiar, that's because it was in the news early this year when a Colorado jury slapped it with a $37 million judgment for wrongly refusing to pay the bills of a woman in a car accident. (The company claimed the woman had hidden evidence of a pre-existing condition. The jury, obviously, disagreed.) And when the layoffs were announced, an article from the Milwaukee Journal-Sentinel noted that reform would ‘undercut one of Assurant's strengths – determining which customers are the best risks.’ I have no idea whether Assurant can find other ways to survive as a business. But, if it can't, then we're better off relying on competitors that can.”

I was struck by the difference in “perspective” on the facts...and would welcome your own unique perspectives.

Disclosure & Transparency is the Least We Can Expect. . .

2010-09-07T11:05:00.006-04:00

The process of participating in the political process has changed dramatically over the course of the past year. In January 2010, the U.S. Supreme Court decided in Citizens United v. Federal Election Commission that, for the purposes of campaign contributions, organizations are citizens and have the right to "unlimited spending in pursuit of political ends." This is a change of titanic magnitude in our political system.

I have very mixed thinking about the decision. I generally support free market and libertarian sorts of ideas—including completely unlimited freedom of speech. But, the power of unlimited corporate contributions in politics does daunt me. In the wake of this decision however, there is one absolute – we must have transparency in these contributions. Whether by individuals or corporations, all donations to political campaigns, political action committees, the 527 advocacy groups, and the host of non-profit organizations that have grown up doing the bidding of political movements, must be publicly disclosed immediately. Without transparency, what we have is a political system driven by propaganda (which is commonly differentiated from ‘advertising’ by its lack of identifiable source).

This issue has new interest in the wake of some recent events. We had the humorous ‘mock news’ reporter Jon Stewart on the “The Daily Show” pointing out that the supposedly terrorism-tainted Saudi prince (whose foundation might contribute to the Islamic center much maligned on Fox News), Walid bin Talal, is not only the biggest non-Murdoch shareholder in Fox News’s parent company (he owns 7 percent of News Corporation), but is also the recipient of Murdoch’s mammoth investments in Saudi Arabia.

Then, there was a great analysis, “Covert Operations: The Billionaire Brothers Who are Waging A War Against Obama,” by Jane Mayer appearing in The New Yorker. Its examination of the political funding apparatus of industrialists Charles and David Koch (Charles G. Koch Charitable Foundation, the Claude R. Lambe Charitable Foundation, the David H. Koch Charitable Foundation, KochPAC, and Koch Industries) is fascinating. These two men, alone, are responsible for a host of ‘political brands’ that we are exposed to every day – the Cato Institute, George Mason University, the Mercatus Center, Citizens for a Sound Economy, Citizens for the Environment, Americans for Prosperity, Century Strategies, and “Tea Party Talking Points.”

I support the right of these individuals to say whatever they want, and to fund the means to move their message forward. However, it is full disclosure and transparency that are a necessity. Unfortunately, the very modest Disclose Act, which requires corporations to show how they spend money in elections, was recently defeated by Republican filibuster. Without that, we are left with citizen action—which frequently comes in the form of consumerism—as our only recourse. Target is one corporation that recently learned exactly how their political investments can impact their relationship with their customers. It donated $150,000 to Minnesota Forward, a group channeling funds to Minnesota Republican gubernatorial candidate Tom Emmer—known for his opposition to lesbian, gay, bisexual, and transgender rights. As a result, the company now faces both a consumer boycott and a movement by institutional stakeholders asking for a "comprehensive review" of Target's political donation process. Still, I think that to rely solely on investigative journalism and institutional investor actions is silly. We need transparency and disclosure. After all, why would political contributors want to hide what they really believe?

The Current Debt Fret

2010-07-09T15:10:00.003-04:00

What a difference two years makes.   Two years ago, the Federal deficit never popped up as a topic of interest in press or policy.   Today, both the popular press and voter polls report on the Federal debt as the cause of angst for average Americans.

First, a few Federal deficit facts: When George W. Bush took office, the debt was ~$5 trillion — when he left office, it was ~$10.5 trillion. According to the U.S. Department of the Treasury, the Federal deficit currently sits at $13.4 trillion according to the Monthly Treasury Statement.

The single largest category of Federal spending is the annual military budget at $700 billion, as stated in “Defense Officials Anticipate Drop In Military Spending.” This is important to point out, since there seems to be some allusions in press coverage that the Federal deficit is largely due to the Stimulus bill and health care reform legislation. In fact, most of the current deficit and most future spending is related to our military entanglements across the world. Since 2004 until the present, the U.S. spends more on military spending per year than the rest of the world combined (World Wide Military Expenditures).

And, while Dr. Robert M. Gates, the Secretary of Defense, has been warning the Defense industries to be prepared for reductions in spending, as stated in the NPR story. I was bemused to hear (later in the same interview) that this warning is only that annual increases will narrow, not that there will be an actual cut in the military budget.

Why should we be concerned about the discussion of the Federal deficit?   Of course, there is always the angst about being a debtor nation, possible increases in personal and business taxes, and American competitiveness – certainly key economic worries.   But, our debts to Gross Domestic Product (GDP) numbers are comparable (a shade higher) to other nations.

To me, the bigger issue is one of priorities. In the future, what are we making strategic resource decisions?   To paraphrase a recent Thomas Friedman’s article, “OP-Ed Columnist: What’s Our Sputnik?,” we need to be investing in those specific area that will produce a strong and competitive country in the future. I think that there is overall agreement that those areas include education of our populace, advancing scientific understanding, and developing new technologies (biomedical, clean energy, environmental controls, communications, and such). I think there is also agreement about the need to invest in human and physical infrastructure – health promotion and rational health security, train and road systems, energy capacity, telecommunications, etc.

The question is whether our current national politics (and national mood) will allow military spending to crowd out our more strategic investments.   I’m not opposed to military spending as part of our investment strategy – certainly national security is a key element in national prosperity. But I do think the current levels of military spending are unsustainable and they cannot be maintained at the expense of our future prosperity.

Service Line Specialization Is The Name Of The Game

2010-06-16T10:28:00.007-04:00

I read, with interest, a recent piece on the future of U.S. hospitals, Service-line strategies for US hospitals, by the consultants of McKinsey & Company. The premise is quite simple – the full service hospital is going to have an increasingly difficult time competing. Their solution? "A commitment to clinical service lines as an organizing paradigm, much as many corporations organize themselves by business unit—is becoming a necessity. . . Specializing in a few service lines allows hospitals to build a critical mass of patients in select areas and to enjoy economies of skill and scale... "

This market focus on specialization – and the need to adopt service line management tools is not limited to hospitals. I see it as a key survival strategy for organizations in the behavioral health and social service niche playing field.

At our 2010 OPEN MINDS Strategic Planning Institute last month, I presented our recent analysis of our post-recession, post-health care reform model for specialists. In a nutshell, there are four likely delivery system market positions – two in facilities and two that are tech-enabled:

• Destination Specialty Services
• One-Stop Health Service Shopping
• Mobile, Home-Based, & Community Care Services
• E-Health & Remote Services

But, that is only part of the strategic positioning story. Within those delivery system market segments, the detail can only be answered by effective service line analysis and management. For your strategic planning – and then for your on-going market strategy implementation and operations management structure – service line management models are key to effective analysis and nimble management during this turbulent market environment. If your current planning isn’t grounded in an organizational view based on service lines, consider next year’s plan as a good place to start today.

Now I Know Why I've Never Aspired To Political Office -- Too Much Reason & Too Many Facts

2010-06-08T14:27:00.000-04:00

I had to laugh when I read The Washington Post piece, "Language lessons for Democrats, from the political brain of Drew Westen." Dr. Westen is the psychologist and neuroscientist at Emory University who wrote the 2007 book, "The Political Brain." His advice to Democrats is to quit using the terms "the environment," "the unemployed" or "the uninsured." I love his comment, "There are a few things if you know about the brain, they change the way you think about politics... If you understand we evolved the capacity to feel long before we evolved the capacity to think, instead of barraging people with facts (the standard Democratic way of talking to voters), you speak to people's core values and concerns. His basic advice is to quit communicating with "reason and facts" since people respond more to "emotional appeals."

I guess this is consistent with some of the new writing about change and leadership. I am particularly taken with the metaphor of the rider and the elephant by UVA psychologist Jonathan Haidt in his book The Happiness Hypothesis. Dr. Haidt's premise is that our emotional side of change is the Elephant, while our rational side is the Rider. Perched atop the Elephant, the Rider often seems to be the leader that holds the reins – but the Rider’s hold is precarious because it’s so much smaller than the Elephant. Any time the Rider and Elephant come to blows about which direction to go, the Elephant (our emotions) wins.

All that said, it's a sad reflection on the state of advice for politicians or managers. I'm reminded of the words of Justice Felix Frankfurter, "Fragile as reason is and limited as law is as the institutionalized medium of reason, that's all we have standing between us and the tyranny of mere will and the cruelty of unbridled, undisciplined feeling…"

Pending Legislation Will Provide Reimbursement Parity for Behavioral Health Provider Organizations

2010-05-05T12:28:00.000-04:00

Just in case you've missed it, there is a bill wending its way through Congress to extend the HIT/EHR incentives that are available to all other health care provider organizations through the Stimulus (ARRA) funds to behavioral health. On April 15, 2010, Congressman Patrick J. Kennedy (D-RI) and Congressman Tim Murphy (R-PA) introduced the Health Information Technology Extension for Behavioral Health Services Act of 2010 (HR 5040). The bill adds mental health and substance abuse professionals, psychiatric hospitals, substance abuse treatment facilities, community mental health centers, psychologists and clinical social workers to those eligible for electronic health record incentive payments established under the American Recovery and Reinvestment Act of 2009 (ARRA). Psychiatrists and psychiatric nurse practitioners are already eligible for this program under existing law.

You can learn about the bill at http://patrickkennedy.house.gov/PRArticle.aspx?NewsID=1770. We'll keep you posted on the status of the bill in our coverage of breaking developments in the field.

Regulation Of Smartphone Applications For Health Care?

2010-04-13T15:52:00.001-04:00

"Medical applications are technically medical devices and therefore subject to federal regulation... There currently are no clear federal measures in place, however, to guarantee their quality and accuracy."

These lines, from the article "iRegulate: Should Medical Apps Face Government Oversight?" in Scientific American, got me thinking about the smartphone as 'medical device'. In February, Jeff Shuren, director of the FDA's Center for Devices and Radiological Health, testified before an FDA committee on health technology. He said: "With the rapid integration of apps into routine healthcare, however, time seems be of the essence. And as many physicians already use apps to check and update patient status, concern about logging crucial data incorrectly is not unfounded... Adverse events resulting from medical apps and other health information technology errors have already been reported to the FDA."

Certainly as we see more 'expert decision support systems' built into smartphone devices, there use in the health care field will expand - and will draw increasing attention from regulators.

Should Mitt Romney Run Health Care Reform Implementation For the Obama Administration?

2010-04-08T16:29:00.001-04:00

Were you as surprised by that question as me? In his piece, The Right Man for the Job - Why Mitt Romney should run Obamacare, Daniel Gross made the case for Mr. Romeny. My initial reaction was skeptical.

But, Mr. Gross outlines his view of the three principal requirements for the job. The first is experience in management, business, and organization. The second is the ability and capacity to commit and to act. The third is relevant experience in implementing a large-scale health-care reform program. Seems like a job just made for Mr. Romney. I am sorry I hadn’t thought about it before...

Innovations Transforming Medicine – And Opportunities For Behavioral Health

2010-04-06T12:01:00.001-04:00

I just read Gardiner Morse's great piece in Harvard Business Review, Ten Innovations That Will Transform Medicine. One of the ten – behavioral economics – reinforced my thinking that care management services for consumers with chronic physical health conditions is a great new market opportunity for behavioral health organizations. "If we all acted rationally, we'd eat right, floss, and take our pills as directed. But of course we can be pretty disobedient about doctors' orders, which not only is bad for our health but costs hundreds of billions of dollars a year. Behavioral economics tools — gentle prods that nudge us to behave in desired ways — may be more effective than any amount of browbeating by doctors... reminders, social pressure, default options, rewards, and other behavioral tricks can be used to improve compliance in stroke and diabetes patients... " I think that aggressive innovation organizations that are currently managing care (longitudinally) for consumers with a mental illness or addiction can be the ones to own the future chronic disease space (and, I think Alzheimer's disease, other dementias, diabetes, and strokes are great areas to start...)

P.S. The ten innovations that will transform medicine (according to Mr. Morse) are:

Checklists
Behavioral economics
Patient portals
Payment innovations
Evidence-based decisionmaking
Accountable care organizations
Virtual visits
Regenerative medicine
Surgical robots
Genetic medicine

Now That Health Care Reform Has Passed, The Rush Countdown...

2010-03-29T11:27:00.003-04:00

You may remember one of the few moments of levity in the incredibly complex and partisan discussions of health care reform came from Rush Limbaugh (surprisingly). In January, Mr. Limbaugh ended up in a Hawaiian hospital with chest pains. At a press conference after his recovery, he said, "Based on what happened here to me, I don’t think there’s one thing wrong with the American health care system. It is working just fine, just dandy.” What Mr. Limbaugh apparently didn’t know is that since 1974, Hawaii has had a statewide employer mandate for health insurance and near universal coverage for health care—a key provision of the now-signed health care reform bills. It was irony worth a chuckle.

Roll forward a month, and Mr. Limbaugh added another moment to remember when answering a caller's question on his radio show. The caller asked what he would when the health care reform bill passed. He responded, "I don’t know. I’ll just tell you this, if this passes and it’s five years from now and all that stuff gets implemented — I am leaving the country. I’ll go to Costa Rica." The irony is that Costa Rica has universal, publicly-financed health care—and one of the highest life expectancies on the globe (78.8 year). The very 'socialized' medicine that Mr. Limbaugh has long opposed. It was a great bit of humor in a very intense public discourse.

But, now the day has come. March 23, 2010, the health care reform bill was signed by President Obama. We have the countdown to March 23, 2015 to look forward to.

The Consumer Pendulum Has Swung: "Speed Dating" Has Come To Health Care

2010-03-22T16:38:00.001-04:00

How far will consumerism extend in the health and human service space? A few weeks ago, I covered the new "eBay" of health care, On-Line Bidding For Professional Services Comes To Health Care. And now we have a new kind of ‘speed dating’ to link consumers and health professionals.

Doc Shop—a program Texas Health Resources launched in fall 2009 to connect patients with obstetrician-gynecologists—is like speed dating, the matchmaking process that lets singles meet a significant number of potential dates in a short period of time. The hospital's first event took place on September 24, 2009. Two others have been held since, and seven are scheduled for 2010. The program has been successful enough that the hospital is expanding it to include pediatricians, with longer-term plans to include other specialists. Those involved in planning the events believe the program is best suited for primary care physicians, where matching personalities for a long-term relationship can be particularly important.

Here’s how it works. About five or six physicians sit at tables while a dozen or so potential consumers rotate through. Every five minutes, organizers signal consumers to move on to the next doctor. There is no cost to consumers, and physicians do not get paid for their time. Participating physicians say the event is a welcome addition to other marketing efforts, such as magazine ads or information on their web sites.

An interesting addition to the marketing planning for health and human service professionals. The question – how would your clinical team fare in this ‘speed dating’ paradigm?

The Top 10 Barriers to Electronic Health Records

2010-03-15T10:12:00.004-04:00

On December 31, 2009, the federal Department of Health and Human Services (HHS) released an interim final rule (IFR) with definitions for certified electronic health record (EHR) technology that will meet the Stage 1 “meaningful use” requirements the Medicare and Medicaid EHR Incentive Programs. Eligible professionals and hospitals must use certified EHR technology to qualify for the financial incentives described in the American Recovery and Reinvestment Act of 2009 (ARRA). HHS will adopt the IFR’s initial set of certification criteria on February 12, 2010.

Once the IFR came out, the behavioral health and human services space was abuzz discussing what was missing, what was unclear, how meaningful ‘meaningful use’ could be—you name it. The other day I came across a great feature written by John Halamka, MD, the Chief Information Officer of Beth Israel Deaconess Medical Center and Chief Information Officer at Harvard Medical School. While teaching a health care information technology (HIT) class at Harvard, he asked his class to read his EHR implementation project and then to “develop a list of barriers to EHR implementation.” The result? Ten major barriers to successfully deploying EHRs:

10. Usability—products are hard to use and not well engineered for clinician workflow.

9. Politics/naysayers—every organization has a powerful clinician or administrator who is convinced that EHRs will cause harm, disruption, and budget disasters.

8. Fear of lost productivity—clinicians are concerned they will lose 25% of their productivity for 3 months after implementation. Administrators are worried that the clinicians are right.

7. Computer Illiteracy/training—many clinicians are not comfortable with technology. They are often reluctant to attend training sessions.

6. Interoperability—applications do not seamlessly exchange data for coordination of care, performance reporting, and public health.

5. Privacy—there is significant local variation in privacy policy and consent management strategies

4. Infrastructure/IT reliability—many IT departments cannot provide reliable computing and storage support, leading to EHR downtime.

3. Vendor product selection/suitability—it's hard to know what product to choose, particularly for specialists who have unique workflow needs

2. Cost—the stimulus money does not flow until meaningful use is achieved. Who will pay in the meantime?
1. People—it's hard to get sponsorship from senior leaders, find clinician champions, and hire the trained workers to get the EHR rollout done. (this was the #1 concern by far)

For States, Governors Say the Worst Is Yet to Come; For Health & Human Service Provider Organizations, July 2011 Is the Launch Date for 'Recession Management' Strategy

2010-03-12T10:25:00.003-05:00

They say health care is recession-proof. But, that's not exactly the case. The health and human services sector has proven to be both recession-resistant and a recession laggard. And—if U.S. governors are right—the start of the ‘recession’ in the health and human service sector will begin on July 1, 2011. The fiscal year that begins in July will be “the most difficult to date,” according to a survey of 45 states released at the winter meeting of the National Governors Association.

States must find a cumulative $18.8 billion to balance their budgets in remaining months of the current fiscal year, and in fiscal 2011, an estimated $53.6 billion in shortfalls awaits, according to the survey. For governors, Medicaid is one of the top budget issues. Medicaid spending for fiscal year 2009 was $335 billion, an increase of 7.8 percent over the previous year. Enrollment increased 5.4 percent in fiscal year 2009 and will grow 6.6 percent in fiscal 2010. Additionally, 3.3 million more people were enrolled in Medicaid in June 2009 compared to the previous year—the largest one-year increase to date.

If you haven't started your management strategy for this time of economic freefall, now is the time. For starters, employ a three-prong recession management strategy consisting of short-term cash management, business development, and preparing for the post-recession marketplace.

For more, check out:

Hypocrisy in Advertising Policy Alive & Well At CBS

2010-03-08T12:09:00.003-05:00

The hypocrisy of the year award has got to go to CBS. If you remember, there was quite a protest by pro-choice organizations about CBS’ decision to air during the Super Bowl an ad featuring Tim Tebow, paid for by Focus on the Family—a politically influential evangelical group founded by James Dobson. The ad, whose slogan is "Celebrate Family, Celebrate Life," features Tebow—who wrapped up his University of Florida career with a Sugar Bowl win this month—and his mom, Pam.

Pam reminisces about being pregnant with Tim while on a missionary trip in the Philippines. She fell ill and was advised to have an abortion. She ignored the advice, and the rest is BCS Championship history.

There was a call from a large number of women’s advocacy organizations to pull the Tebow ads. But, in an interview with Reuters, CBS spokesman Dana McClintock said that they no longer had a blanket filter on advocacy submissions for ad slots. "We have for some time moderated our approach to advocacy submissions after it became apparent that our stance did not reflect public sentiment or industry norms on the issue.”

But what about the commercial CBS turned down for airing in the Super Bowl—an ad for GoDaddy.com, in which a retired football player "finds his feminine side" and launches a lingerie company? And, in early February, the CBS Corporation and Neutron Media Screen Marketing rejected a paid advertisement from the NORML Foundation, the educational arm of the National Organization for the Reform of Marijuana Laws (NORML) that was intended to appear on the CBS Super Screen billboard in New York City's Times Square.

The fifteen-second ad, which asserts that taxing and regulating the adult use and sale of marijuana would raise billions of dollars in national revenue, was scheduled to appear on CBS' 42nd Street digital billboard beginning on Monday, February 1, 2010.

Representatives from Neutron Media approached NORML in mid-January about placing the ad, which was scheduled to air 18 times per day for a two-month period. The NORML Foundation entered into a contractual agreement with Neutron Media to air two separate NORML advertisements, and produced an initial ad exclusively for broadcast on the CBS digital billboard. Days after NORML submitted the ad, the organization received the following e-mail, dated February 3, from a Neutron Media representative which stated, "I just received word from CBS and they will not approve your ad. If CBS changes their morals we will let you know."

I think all ads should run—regardless of their advocacy position. So, in the interests of equal time, see the GoDaddy.com ad at http://outofbounds.nbcsports.com/2010/01/post-168.html.php). NORML's 15-second animated advertisement is available online here: http://www.youtube.com/watch?v=0tqW9Kj8DVU.

The Simple Solutions to Potential Phyisican Shortages

2010-03-04T13:26:00.000-05:00

The December 17 issue of Business Week had a provocative headline—The Coming U.S. Doctor Shortage: Health-care reform will mean 30 million more patients—and bigger crowds in waiting rooms. I thought the positioning of this piece played into the 'fear of health care reform' camp that looks at the nation's health as a zero sum game. If you give minimal coverage to all, the rest of us with insurance will suffer. But the piece did raise some interesting points:

In 1997, lawmakers placed a cap on the number of medical residencies in order to contain costs under Medicare, which pays for most of these training slots.Medicare pays $100,000 a year per residency, at a total cost to the program of about $9 billion. The funding began in 1965 when the U.S. was preparing to extend government health coverage to 19 million elderly Americans. As the Medicare rolls grew—to 45 million by the end of 2008—a cap was placed on the number of medical residencies to control spending.
According to the U.S. Department of Health and Human Services, last year there were nearly 17,000 fewer primary-care doctors than needed in inner-city and rural areas. The Association of American Medical Colleges predicts that by 2025 there will be a shortage of as many as 159,300 doctors.
An amendment to the health-care reform bill—proposed by Senate Majority Leader Harry Reid (D-NV), Charles Schumer (D-NY), Bill Nelson (D-FL.)—would add 15,000 residencies at a cost to Medicare of about $1.5 billion to anticipate and prepare for this shortage

What caught my attention in the article was this handy chart—showing the growing demand for services and the almost-flat supply line. I believe we can flatten the demand line for physicians and increase the supply line with just a few policy changes.

On the demand side, if we encourage individuals to take more control of their own health care, demand for physician time will decline. There are also a variety of technological substitutions for physician office visits and an array of non-physician health professionals that can fit the bill.

On the supply side, there are two major ways to enhance supply. First, use technology to increase physician productivity—less paperwork, e-health to extend reach, and more. The other way is to pay primary care physicians more. Payment policies have favored procedure-oriented specialists—and the physician’s choice of specialties reflects this.

"Consumers Who Buy Individual Health Policies Feel Trapped"

2010-03-02T23:38:00.000-05:00

The headline in the February 20, 2010, edition of The Los Angeles Times tells a story, "Consumers who buy individual health policies feel trapped. They have few options other than dropping coverage as insurers raise rates and slash benefits. Insurers blame the soaring cost of medical care and the churn of customers in the individual market."

No argument from me; for individual and small group health insurance policies, the rates—and rate increases—are crazy. But, the insurers' complaint about churn is spot on. Until we have universal health care coverage for 95% or more of the population, this ‘shift the risk’ game will continue. There is nothing that consumers or insurers can do about it. Solutions? Only two.

1. The government provides catastrophic health insurance for everyone, and/or

2. Employers are required to provide—and individuals are required to buy—health insurance.

Hopefully, our representatives in Washington will eventually understand these basic health care financing principles.

You May Or May Not Like It: 10 GOP Ideas for Health Care Reform

2010-02-26T12:08:00.000-05:00

A few weeks ago, Newt Gingrich with the president/CEO of the National Center for Policy Analysis John C. Goodman jointly responded to President Obama's challenge for Republicans to show him a better idea on health care reform. Their ten ideas, outlined in the Wall Street Journal’s “Ten GOP Health Ideas for Obama” are as follows, with my reactions in red.

Make insurance affordable. This could be done by reforming the "arbitrary and unfair" taxation on health insurance. (Read: no more tax exemptions on employee health benefits)
Make health insurance portable. Employers should give employees insurance that can be brought from job to job, and people should be able to buy insurance across state lines. (Read: eliminate state-specific regulation of insurance comapnies and move to interstate insurance)
Meet the needs of the chronically ill. Help them take charge of their own care with Health Savings Accounts. (Not sure what this means)
Allow doctors and patients to control costs. Doctors and patients should be liberated from government-imposed payment rates that reward physicians for treating the sick but not for keeping healthy people healthy. (Not sure what this means)
Don't cut Medicare. Medicare's on an unsustainable course, but the $500 billion in cuts the Democrats propose are not the answer. (Interestingly odd for Republicans)
Protect early retirees. A bridge to Medicare can and should be built to help the millions who retire before they qualify. (Not sure what this means)
Inform consumers. Government data on cost and quality should be made public. (Of course. . .)
Eliminate junk lawsuits. "We do not need to study or test medical malpractice any longer," Gingrich and Goodman write, pointing to Texas' liability protection efforts as a model. (As a consumer, I'm skeptical of eliminating legal redress for medical malpractice without more regulation to 'disbar' bad physicians. As a health care analyst, the savings are only in the 1.5% range.)
Stop health care fraud. Approaches including third-party liability verification, and electronic payment can help cut the $120 billion lost to fraud every year, (Of course...)
Make medical breakthroughs accessible to patients. Red tape should be cut to get new drugs and treatments to patients faster. (Good on paper but full of practical, legal, and scientific problems.)

So what do you think? Can this GOP hit list be married with the existing bills to give us something resembling universal coverage with cost containment? Let me know what you think!

Annual Cost of Treating Diabetes: $10,000; Heart Attack Treatment: $45,000; Prevention: Nada

2010-02-22T10:12:00.000-05:00

So what gives? A new study by the American Journal of Preventive Medicine, “Patient Costs As a Barrier to Intensive Health Behavior Counseling” found that if there is a fee for participating in weight loss or smoking cessation programs, neither consumers or health care professionals are interested. When there are fees (of any type) for participating in the programs, health care professionals referred 97% fewer consumers; of those referred, 81% fewer consumers actually followed through and participated.

To me, this speaks to two issues. First, health care professionals don't believe in the value of prevention programs—or they’d refer more of their patients. This is bad news for programs in the disease management space. Second, consumers are not connecting their health status with their behaviors—and the long-term consequences (in quality of life, cost, mortality, etc.) of their behaviors. This is bad news for behavioral health provider organizations and professionals.

I'm not sure what the solution is to this dilemma. And, I'm not so sure that making all of these programs 'free' is the best policy choice. The research is pretty clear that without some financial participation (no matter how minimal), consumers have a lack of engagement in health services. But, helping to change perceptions of the value of prevention programs is the bigger issue.

Computer-Assisted Therapies Speed the Bridge Between Behavioral Health and Physical Medicine

2010-02-19T10:26:00.001-05:00

I was surprised to see this headline on the DHHS web site, "Biofeedback Now Seen as 'Regular' Medicine: Computer-assisted treatment has joined mainstream for pain, anxiety and more". But it makes sense. As our knowledge of both the physical nature of behavioral disorders and the behavioral nature of physical disorders has continued to grow, it was inevitable that we would eventually begin to see the 'therapies' overlap.
The emerging group of tech-enabled therapies—both stimulation-based neuromodulation therapies and exercise-based therapies (like biofeedback in the DHHS article)—will help to drive the health management integration that has been held up as the ideal. That said, I think the going will be slower than necessary, mainly because there is a great deal of professional resistance (both in physical medicine and in behavioral health) to embrace the new treatment models.

On-Line Bidding For Professional Services Comes To Health Care

2010-02-15T17:12:00.003-05:00

Ready or not, tech-enabled consumerism continues to morph the relationship between professionals and the consumers they serve. I've written before about both the move to on-line ratings services for health care professionals (RateMDs; RevolutionHealth; Vitals.com; DrScore.com; HealthGrades.com; MDNationwide.org; ConsumerHealthRatings.com; and Rehabio) and the on-line web sites that sell excess professional capacity by the minute (ETherapistsOnline; MyTherapyNet; WebAddictionTreatment.org; and AsktheInternetTherapist.com). These categories of health care marketing organizations represent something akin to American Idol and HOTELS.COM in the health and human market space. Well, the push of technology is taking this one step further—we now have the progeny of when eBay meets health care.

The eBay of health care may soon be PriceDoc.com. The company just received a U.S. patent on its soon-to-be-released system for on-line bidding on health services which will, according to their press release, make "PriceDoc.com the only online site where patients can "make an offer" for healthcare services with verified providers." The initial focus of PriceDoc is consumers who are uninsured, underinsured or seeking elective procedures with provider organizations and professionals who accept cash or credit card payments. (The service categories on their web site include dental, medical, vision, cosmetic, mental health, weight loss, allied health, and alternative health.)

You may think this type of purchasing model couldn't change the health care space. But don't forget eBay, founded in 1995 selling office equipment and plane tickets; had 250,000 transactions in 1996; and by January 1997 the site hosted 2,000,000 auctions. Bottom line? We can’t rule anything out when it comes to which tech trends will shape the sector. Stay tuned.

Glad Health Care Reform is Dead? Unlikely, if You're in the Health Care Business (or a Small Business)

2010-02-11T13:37:00.007-05:00

The burden of uncompensated care looms large for most health care organizations—especially with the press pronouncing the "death" of health care reform. For the most part, the term 'health care reform' refers to some package of legislation that has two elements—increasing the number of Americans with some form of health care coverage (particularly catastrophic coverage) and putting in provisions to reduce overall U.S. health care costs. The first is of particular interest to health care provider organizations and the second to small employers like my organization.

Now, you may be like one of my many friends who is celebrating the death of the current set of health care reform proposals. You may say that the free market alone is enough to both reduce costs and provide expanded coverage (one leading to the other)—by having individuals pay for their own health plans and health services. While I'm a fan of many free market elements in health care reform (including consumer vouchers for purchasing plans), I would caution those of you in that camp that the free market alone won't solve the coverage and cost challenges that face us (for many reasons too numerous to list here).

The rumors of the death of any health care reform proposal are going to continue to destabilize any organization in the health service delivery system that is not solely a private pay operation. The rising number of uninsured and inexplicably underinsured Americans will overwhelm the charitable capacity of the delivery system without some paradigm shift. But, I would caution my friends in the health care field to realize that we can't afford universal coverage without cost containment. It's just not a fiscal possibility.

And, as a small employer that provides health coverage to our team, I can state unequivocally that no health care bill will cause increasing stress—both financial and ethical. Over the past two years at OPEN MINDS, we have had two proposed increases in the cost of health care coverage—15% in 2008, and 40% in 2009. So, I wasn't surprised (though the press seemed shocked) at the recent decision by Anthem to raise their premiums by 30-39%.

I hope you'll join me in pushing our representatives of both parties to take action—to move toward a system of universal coverage (even if only for catastrophic coverage) and to come up with rational solutions to reducing health care costs.

Incorporating Social Media Into Your Strategic Planning

2010-02-08T18:35:00.007-05:00

Gartner has recently released its analysis of social media, with five predictions for where it is headed (see “Gartner Reveals Five Social Software Predictions for 2010 and Beyond”)—predictions that have implications for both organizational management and for marketing strategy in our field:

By 2014, social networking services will replace e-mail as the primary vehicle for interpersonal communications for 20 percent of business users.
By 2012, over 50 percent of enterprises will use activity streams that include microblogging, but stand-alone enterprise microblogging will have less than 5 percent penetration.
Through 2012, over 70 percent of IT-dominated social media initiatives will fail.
Within five years, 70 percent of collaboration and communications applications designed on PCs will be modeled after user experience lessons from smartphone collaboration applications.
Through 2015, only 25 percent of enterprises will routinely utilize social network analysis to improve performance and productivity.

My takeaways of the management implications of these developments:

Your organization will need social media presence (however limited) to be included in all of the business networking discussions in your market space.
In planning your organization's use of social media, it's important to focus on the solution and not the technology. Executives will need to press tech departments into accepting a solution-based approach to their work—and participating in the evolution of social media's role in your organization.
The smart phone user interface will soon become our standard computer interface—it's not just the hardware that is merging.
Process analysis in your organization will need to include the social media-based interactions between team members and with customers.

Stay tuned for more coverage on the social media impact on the health and human service field.

On Making College Relevant

2010-02-01T13:44:00.003-05:00

“Making College ‘Relevant’”, a piece in the December 29, 2009, edition of The New York Times, was a classic example about how new college graduates are ‘missing the boat’ about being hired. As the CEO of a company that hires both college interns and new college graduates, I want to give some free advice:

Learn to write (it doesn't matter what your major is—this is the universally necessary skill for most businesses)
Computer skills are a must—and I'm not talking about using Twitter; the basic skills you need are word processing, spreadsheets, and web searches (others are a bonus)
Be able to do basic math and understand the meaning of charts and graphs
Remember that in the information-based economy workplace, attention to detail matters—your mother isn't there to clean up your work for you
Keep in mind that most of your personal preferences are not relevant on the job—if you're not happy with what you're doing, save your comments for after work or find a new job.

For college graduates (of whom there are many) who cannot master the first three items, it is really a systemic fault at the college level. No one should graduate from an academic institution without those basic skills.

History Has A Way of Repeating Itself: Institutions & Citizens With Mental Illness

2010-01-31T11:24:00.005-05:00

The future of institutions as long-term residences for persons with mental illness is certainly an integral part of the discussion about mental health policy. Usually those discussions focus on state budgets and Medicaid reimbursement and compliance with Olmstead. But, I was intrigued with a recent piece on Scott Hensley's blog on npr.org “A Peaceful War on Mental Institutions”—coverage of a different chapter in the history of mental institutions.

I never realized that many conscientious objectors in World War II were assigned to mental institutions in lieu of military service. Their experiences are documented in a recent piece on NPR ("WWII Pacifists Exposed Mental Ward Horrors") and in two books—Acts of Conscience: World War II, Mental Institutions, and Religious Objectors (by Stephen Taylor and published by Syracuse University Press) and The Turning Point: How Men of Conscience Brought About Major Change in the Care of America's Mentally Ill (by Alex Sareyan and published by American Psychiatric Press).

As I read this tale of the evolution of human conditions within our mental institutions, I was first struck by how much had changed. Then my thoughts wandered to the millions of Americans with mental illness in our corrections system. If we had the same undercover reporting of conditions of these citizens, would the photos be far different?

For more information on mental health in the corrections context, check out:

Four Reasons We Need Comparative Effectiveness Research

2010-01-25T16:36:00.005-05:00

Regardless of the final direction health care reform legislation will go, comparative effectiveness research (CER) will be a part of it. While many see CER as a vital piece of the puzzle, some in the health care industry are on the fence about its actual value in improving health care as a whole. A New England Journal of Medicine piece I read recently, by Alvin I. Mushlin, M.D., and Hassan Ghomrawi, Ph.D., M.P.H., “Health Care Reform and the Need for Comparative Effectiveness Research” gave four straightforward reasons for how/why CER is both valuable and necessary in our existing system:

Findings from CER will provide a buffer against “blind” cost containment.
CER can identify preferred therapies, promoting changes in care and outcomes by identifying and validating such treatments. Such research suggests ways for new financial incentives to be applied both safely and effectively.
CER should enable innovation in medicine, by creating ‘disincentives’ for the development of “me too” drugs and devices, and by raising expectations and demands for clear evidence of superiority.
CER serves as what the authors call the “first line of defense against blind cost containment,” and can serve as a stimulus for the academic medical and public health communities, thus resulting in greater demand and more opportunities for physicians-scientists to get in on the research.

Let’s wait to see how CER fares in the final health reform bill—and if either side stifles the progress in science and service delivery that CER can bring about and that the health care system as a whole desperately needs.

Medical Loss Ratios: A Necessary Mandate in Health Care Reform

2010-01-21T10:02:00.002-05:00

I was heartened to see that the Senate version of the health care reform bill would set the medical loss ratio for health plans at 85% for large group plans and 80% for small group and individual plans, and that the House set everyone's rate at 85%. The original proposal by Senator John D. Rockefeller of West Virginia had the ratio at 90%—a number rejected as unrealistic.

And, the reform bills have a penalty clause built in for insurers failing to hit the prescribed medical loss ratio (MLR)—they have to rebate the difference to their customers. See "To Your Health: How Congress plans to get insurers to spend money on actual health care" by Slate writer Christopher Beam. For major insurance companies, this wouldn't change much. The average MLR of for-profit insurance plans offered to large employers is about 84%. Small employers, or companies with 50 or fewer workers, have an average MLR of 80%. But, in the individual insurance market, the MLR is around 70%.

While this is a great start, I think 80% is too low. And, the devil is in the details, so to speak. The reform bills are still defining what exactly 'health care spending' is—a critical set of definitions. Stay tuned

Six Big Issues Remain in Health Care Reform

2010-01-19T13:03:00.001-05:00

The health care reform bill tug-of-war currently happening between the House and Senate is too much for many of us to keep up with. I took interest with an article in Slate by Christopher Beam that includes a hit-list of those health care reform issues that still need to be ‘hammered out’ in the final bill. His six issues include:

The exchanges—while the House bill would create a national exchange, the Senate bill would create a series of state-based exchanges. There’s no happy medium. It is either state or national.
The mandates—what will be the real penalty for not buying health insurance? The House bill would charge a 2.5% tax on all income above the filing threshold ($9,000/individuals or $19,000 for couples), while the Senate bill would impose a flat penalty, which itself fails to acknowledge the wide variance in American income levels and their ability to pay up. The employer mandate is a big one as well; will employers pay an 8% tax on total wages or levy a $750 fine per employee? Who will be eligible for exemptions?
Medicaid expansion and subsidies—the House bill would make Medicaid available to individuals earning up to 150% of the poverty level, while Senate bill would expand it 133%. The differences are in the subsidies, in that the House bill provides far more support for families at or below 300%, while the Senate bill seems to focus more on middle income families between 300% and 400%.
CHIP—key questions posed by Beam: “Does Congress really want to end the Children’s Health Insurance Program and push kids into exchanges and Medicaid, as the House bill would do? Or does it want to extend CHIP until 2015, as the Senate bill would do?
Narrowing the ‘donut hole’—the gap in Medicare coverage known as the ‘donut hole’ is addressed far more in the House bill, which phases it out altogether by 2019 by ‘filling’ it with money from the pharma industry. The Senate bill would only close the gap halfway (and only temporarily).
Paying for it—the House would levy a 5.4% surtax on individual income above $500,000 while the Senate would tax plans that cost more than $8,500 for individual and $23,000 for a family; Senate would also tax indoor tanning services (yes, seriously).

As our eyes dart back and forth between this legislative ‘volley,’ I will be interested to see how flexible the House and Senate are on certain issues—and which issues they refuse to compromise on.

Hawaii’s Lessons in Universal Coverage Useful In Framing The Health Care Reform Discussion

2010-01-17T21:48:00.002-05:00

Emily Friedman, in her recent piece “Almost Paradise” featured in Hospitals & Health Networks, gave a great history of Hawaii’s efforts to establish and maintain universal health coverage for its residents (it ranks second among the states in terms of population coverage). And, while the history was fascinating in terms of its magnification of the issues being discussed today in Washington, Ms. Friedman’s “ten lessons learned” were even more compelling for thinking about our current reform efforts:

Every state is unique. Whatever the health care reform prescription coming out of D.C., if it is a ‘national’ as opposed to state-based approach, variation at the state level is key to long-term success.
The right people have to be in the right places at the right time. To get big initiatives passed, alignment behind core tenets is necessary in several sectors of government. Given the current state of certain parts of the U.S. Congress (the ‘just say no’ contingent), this is problematic—it’s hard to figure out what they would support.
The political, economic, and cultural environments have to be right. Passing an expansion of health care coverage is difficult now given the economics. The proponents need to do a better job of making the case for expansion of health care coverage in the current context.
Having a predominantly nonprofit health care sector helps. In Hawaii, at the time that health care reform was passed, the health care sector was predominantly non-profit. In the current debate, there has been no end of the controversy about the role of for-profit sectors of the U.S. health care system.
If costs are not controlled, nothing will work in the long term. If costs keep on escalating, there is no coverage program in the world that can continue to function—public or private, employer-based or individual.
Mandates help but are difficult to enforce. Whether mandates to purchase insurance or mandates to provide coverage or mandates for taxation, mandates are easy to pass and hard to enforce. Complete compliance can never be assumed.
Truly universal coverage is impossible to achieve. "Universal coverage" is a great goal but a practical myth. Some small percentage(5% is a common figure cited by scholars ) of people participate, even if the coverage is free.
Providers can (or will) absorb only so much loss. There is much discussion about the end of fee-for-service and moving risk to provider organizations. This is a great potential model but cannot be the only cost containment measure.
Don't underestimate your opponents. Those who oppose an idea are generally more fervent than those who support it, especially when the benefits will largely go to people other than themselves.
All situations change over time. Flexibility needs to be built into any health care reform initiative. Accommodation of change (financial, political, technological, etc.) are necessary for health policy initiatives to last.

Brain Scans Make Their Way To Court

2010-01-12T10:39:00.002-05:00

Brain scan evidence that defense attorneys claimed show a defendant’s brain as psychopathic was allowed into the sentencing portion of a murder trial in Chicago, according to a November 23 report, “Courtroom First: Brain Scan Used in Murder Sentencing” from one of my favorite pubs, Wired Science. Not that it helped the intended cause—the defendant was found guilty and sentenced to death. But, with the accuracy rate of brain scan data ranging from 76% to 90% in identifying deception (according to a 2008 University of Pennsylvania Center for Cognitive Neuroscience publication “Detection of Deception with fMRI: Are we there yet?”) the brain scan has equal or better accuracy than lie detectors. And, discerning judges and juries will likely find brain scans to be more credible than hired-gun forensic psychiatrists and psychologists. Look for more diagnostic metrics in the courtroom.

Antidepressants May Change Your Personality

2010-01-08T13:37:00.002-05:00

“Antidepressants May Change Your Personality” was the lead story of the recent daily health news update from healthfinder.gov, the U.S. Department of Health and Human Services’ service to provide current health info to the public. My initial reaction was that this isn’t news. (I’m not making any value judgments about whether this is good or bad, by the way.)

The story cites the research of Tony Tang, an adjunct professor of psychology at Northwestern University in Evanston, which found that taking antidepressants may not only help alleviate depression, but could also make you more extraverted and less neurotic. The study, “Personality Change During Depression Treatment: A Placebo-Controlled Trial,” featured in the December 2009 issue of Archives of General Psychiatry, posits that extraversion—often associated with positive emotions—is believed to help protect from depression, while neuroticism—the tendency to experience negative emotions and emotional instability—is thought to contribute to depression.

The study revives some of the work by Peter D. Kramer (author of Listening to Prozac and Against Depression) following the introduction of Prozac (though the premise is certainly extended to all types of antidepressants) about social questions surrounding the benefits and problems of “norming” one’s personality in the name of treatment. Though this question may seem a bit passé, it is a topic that will certainly get more traction as cosmetic neurology and the concept of “normal” wends its way through the mental health field.

For more on this topic, check out:

Is Cosmetic Neurology the Behavioral Health Business of the Future? The Controversy Over Drugs That Build “Mental Muscle”

Savings From Early Release of Prisoners A Budget Folly Without Some Planning

2010-01-05T22:29:00.000-05:00

We are soon to have a number of states release county and state prisoners early—in order to reduce corrections budgets. While I’m all for ending our practice of incarcerating Americans for lack of available metnal health and addiction treatment, I think the current wave of early releases may actually end up costing us more without some planning.
The ‘Exhibit A’ for my conclusion is a recent report in Psychiatric Services on Bazelon Center's Blueprint for Community Reentry.

The piece has some grim statistics—approximately 16% of all prison and jail inmates have a serious mental illness, and more than half have a clinical diagnosis, a treatment history, or symptoms of mental illness. Within 18 months of release, 64% of those with mental illnesses are rearrested—more than twice the rate of those without mental illnesses. Entitlements such as Medicaid and Medicare, veterans benefits, and Social Security income support enable individuals to obtain mental health care, housing, and other services. Without assistance, released inmates often wait months for benefits—a major factor in their high recidivism rate. However, only a third of inmates receive benefits restoration planning that is essential to preventing reincarceration.

Advice for Preparing For Parity in 2010

2009-12-29T14:14:00.001-05:00

We're on the eve of the implementation of behavioral health parity legislation. Medicare has released the procedures for implementation of parity for their beneficiaries—see “Medicare Claims Processing Transmittal 1843: Outpatient Mental Health Treatment Limitation.” The regulations for the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act will be released in January of 2009, “Wellstone Act Mental Health Parity Effective Date Delayed Until 2010.”

But the various pieces of parity legislation will only be as meaningful to consumers as their implementation. To that end, there is a great piece in the December 2, 2009 issue of Medical News Today, “Lessons From the Implementation of Mental Health Parity in California.” Coauthors Margo L. Rosenbach, Ph.D., Timothy K. Lake, Ph.D.; Susan R. Williams, M.P.P., also affiliated with the Mathematica Policy Institute, and Jeffrey A. Buck, Ph.D., offer three pieces of advice from their research:

The need for increased oversight of health plans—monitoring health plan performance related to access and quality, in addition to monitoring coverage and costs;
The need to look at the breadth of diagnoses covered by health plans; and
The need to ensure consumer awareness of parity—mounting a campaign to education consumers about their insurance benefits.

Three points we should all put on our 2010 new year's resolutions!

Therapy Versus Income: Their Comparative Effects on "Happiness"

2009-12-21T14:07:00.002-05:00

If your organization is looking at increasing its private pay services, a new study, “Money or Mental Health: The Cost of Alleviating Psychological Distress With Monetary Compensation Versus Psychological Therapy” published in Economics Policy and Law and summarized in Science Daily’s "Psychological Therapy 32 Times More Cost Effective at Increasing Happiness Than Money" provides some powerful ammunition. The study found that four months of therapy increased "happiness" (as defined by the researchers Christopher J. Boyce and Alex M. Wood at the universities of Warwick and Manchester) as much as a $40,000 raise. The researchers concluded that "The research therefore demonstrates that psychological therapy could be 32 times more cost effective at making you happy than simply obtaining more money."

Despite the happy news for psychotherapy practices and the many vagaries of calculating well-being and happiness, the study speaks to the struggle of government policymakers in determining the 'relative value' of funding health services. "The researchers further draw on two striking pieces of independent evidence to illustrate their point—over the last 50 years developed countries have not seen any increases to national happiness in spite of huge economic gains. Mental health on the other hand appears to be deteriorating worldwide. The researchers argue that resources should be directed towards the things that have the best chance of improving the health and happiness of our nations—investment in mental health care by increasing the access and availability of psychological therapy could be a more effective way of improving national well-being than the pursuit of income growth."

These cost-benefit analyses, in health care analyzed through the lens of comparative effectiveness, will become more frequent as we have more data available through inoperable EMRs and there is greater pressure to reduce health care costs.

Why the Attrition of Organizations in the Behavioral Health & Social Service Field?

2009-12-16T12:21:00.004-05:00

An article in the November 30, 2009 issue of The New York Times sparked my thinking, once again, about the high attrition rate of behavioral health and social service organizations. The article, "Less Diversity in Supervisors of Foster Care” cites the statistic that under the watch of John B. Mattingly, appointed in 2004 to head New York City’s Administration for Children’s Services, the number of foster care agencies has dropped from 43 to 33.

A little later in the article, Fatima Goldman, executive director and chief executive of the Federation of Protestant Welfare Agencies, observed that the cause was just a lack of time for agencies to develop the management infrastructure needed for the current environment. “There just hasn’t been time for some agencies to build the core infrastructure to survive such a dramatic shift that’s occurred over the last few years, especially the overall economic downturn…That is the nail in the coffin for so many organizations.”

Talking about ‘time’ alone as the demise of many of the non-profit organizations isn’t dealing with the ‘whole picture’. There are a few other factors:

Inability (or unwillingness) of public purchasers to measure and compare the performance of their contract organizations—have transparency in performance and make future referral, rate, and contracting decisions on that performance data
View of the leadership of the organizations in the field that management capabilities are not integral to continuing their service mission; this has been permitted to exist by public purchasers for years and reinforced by the good intentions of management teams.

Time is now an issue for many organizations in the field. They have, indeed, waited too long to put in the management systems—financial, IT, planning, development, etc.—that they need to make it through the next decade.

Six Ideas That Would Change Health & Human Services

2009-12-14T10:57:00.002-05:00

Wired Magazine never fails to make me think. The October 2009 issue featured “The Smart List: 12 Shocking Ideas That Could Change the World.” There were six ideas that have specific relevance to our field:

Recruit Autistics. "A preternatural capacity for concentration and near-total recall" makes autistic folks ideal software engineers according to Thorkil Sonne, who founded Specialisterne in Denmark, an IT consultancy that hire mostly people with autism-spectrum disorders.
Embrace Human Cloning. Human clones walk among us—identical twins—so why not take in vitro fertilization to its logical conclusion?
Make Health Risk Management Meaningful. According to Ralph Keeney, 55% of deaths for people aged15 to 64 are now due to their own decisions—compared to 5% a century ago. Provide people with better calculations of risk (for not using seatbelts, not exercising, bad diets, etc.) and then adjust health premiums accordingly.
Release All Nonviolent Offenders in Prison. Incarcerating nonviolent criminals costs us $22,000 per year—and has no social gain. Make nonviolent offenders go to counseling, get an education, do public serivce, and repay their victims.
Legalize Assisted Suicide. Ludwig Minelli, founder of Dignitas, a right-to-die organization, believes that prohibiting suicide doesn't keep desperate people from trying. Instead, provide dignified options—and counseling for people considering suicide.
Forget Medical Privacy. Guest commentator Jamie Heywood of PatientsLikeMe believes "privacy has been used as an excuse by those who have a vested interest in hoarding" health care information. He wants us to share our personal data on-line in social communities.

You may or may not agree with them—but, if implemented, they certainly will change our world.

Technology Has Made Democratic and Republican Parties Unfortunately Irrelevant

2009-12-07T10:28:00.002-05:00

After November’s election results, I’m left wondering…was it a referendum on the President? Where were all those young Obama supporters? Is the GOP dead of its own internal bickering? That independents would within one year swing from Obama enthusiasts to backing decent-to-weak Republicans in Virginia and New Jersey is “simply astonishing,” writes The Wall Street Journal opinion editor.

I don't think it's so astonishing. But, it means accepting the fact that technology has made both political parties—as they currently operate—irrelevant. The world of Internet information; web-based political advocacy groups; and flash mobs (e.g. ‘tea party’ folks) has changed the political landscape. Political parties no longer have coherent platforms that mean anything to anyone and they don't have the ‘member control’ that allows them to mobilize voters. In the future, the winning candidate (and the winning party) will be one who can engage the independent voter around specific issues by using technology to build candidate-specific coalitions of specific voter and interest groups.

For health care reform, both parties are at risk. For the Democratic Party, they're going to need to realize that Americans are skeptical about the operation of the current 'public options' (Medicare, Medicaid, IHS, TRICARE, VA) and don't want to abandon their perceived personal ability to pick a health plan or a professional. Republicans are going to have to go beyond the 'party of no' and "Kill the Bill" rhetoric. Americans know they’re in danger of losing health insurance when they lose their jobs; that many health insurance company policies are nightmares; and that most of us are one serious disease away from bankruptcy. The party that ignores the 'middle view' on health care reform will pay the political consequences for whatever happens with health care.

New Thinking for Your Five-Year Plan

2009-12-04T14:41:00.002-05:00

I recently presented at a state behavioral health association meeting where, to put it mildly, the execs in the audience thought my five-year projections were a bit 'wild'. I heard many comments like, "That will happen eventually, but certainly not in five years…"

But even my view of the future of the health and human services field was given a 'big shock' by the remarks of Google CEO Eric Schmidt at the Gartner Symposium/ITxpo in Orlando. Mr. Schmidt was asked to answer the question, "What will the Internet look like five years from now?" Here are a few of the trends he is working into the five-year strategic plan for Google:

The next five years will outstrip the factor of ten that we now know as Moore's Law—computers’ capabilities will be doubled (speed, storage, reduced cost, etc.) in five years—and not ten
Within five years, there will be widespread broadband access well above 100MB in performance—in other words, super-fast bandwidth for real time audio and video communication
Distinctions between TV, radio, and the web will go away—facilitated in part by inexpensive, fast broadband access
Real time user-generated information on the web will increase—also facilitated by inexpensive fast broadband access—and the will be including it in search results, and more critical, in ranking
Web users will expect to jump from one application to another seamlessly (much like today's teenagers)—and will demand applications that permit this
Five years from now the Internet will be dominated by Chinese-language content.

What does it all mean for our field? I don't know yet, but our team at OPEN MINDS is working on the answer to that very question. Stay tuned.

My Two Cents on Health Care Reform

2009-11-24T14:36:00.003-05:00

I'm opposed to a new public option health plan & want more competition.

Many of my colleagues are surprised when they hear that I am—like many Republicans and "Blue Dog" Democrats—opposed to the current proposals for a new public option health plan. But, after a brief explanation, both the dismay of the public option folks and the applause from public option opponents ends.

I'm not opposed to government-offered health plans—or to competition. In fact, I strongly encourage both. On the competition side, we have a perfectly fine model for offering Americans a choice among public and private health plans, the Federal Employee Health Benefit Plan (FEHBP) model, which currently offers over 300 health insurance choices to Federal employees. My proposal? Give every American a voucher and let them pick between a wide variety of public and private plans (assuming the plans offered meet minimum requirements for coverage, etc.)

That said, I am opposed to the creation of a new public option health plan for two reasons. We already have 60 public health plans that could be 'options' without creating another new government infrastructure. Don't know what I'm talking about? Serving 30% of Americans already are these 60 plans:

TRICARE
Veterans Health Administration
Medicare
Healthcare Group of Arizona
Indian Health Services
55 Medicaid plans—each with a variety of public and private options within those

My point is that there is no reason to duplicate the administrative expense of these 60 plans and create another public option health plan. Let's just open up the 60 existing public option plans—and the 300+ plans available under the FEHBP—to the American public.

For a great description of existing U.S. public health benefit plans, check out the reviews at propublica.com, Grading the Public Options That Already Exist.

Medicaid & Mental Health: A Look Ahead

2009-11-20T10:39:00.001-05:00

Don't miss the great piece "Recent Changes in Medicaid Policy and Their Possible Effects on Mental Health Services” by Jeffrey A. Buck, Ph.D., Center for Mental Health Services, Substance Abuse and Mental Health Services Administration, in the November issue of Psychiatric Services. If you were one of the few remaining people in the field who didn't think that Medicaid funding has come to indelibly change public mental health systems—and will continue to do so—this is a great synthesis of the current and future market effects.

On the system side, Dr. Buck identified the following Medicaid-driven system effects that have already occurred:

A larger role for state Medicaid authorities in state mental health services and a corresponding decline in the role of mental health authorities;

Service delivery privatization via Medicaid managed care arrangements which privatize many functions previously provided by public entities

Increased funding for community-based mental health care

Increased difficulty in using Medicaid funds for areas not clearly defined within the program;

Increased accountability of individual service providers via the Medicaid Integrity Program

Movement away from incentivizing psychiatric institutionalization

Dr. Buck also looks ahead to future policy changes. A few are ‘more of the same’—an increase in the role of Medicaid authorities and the growth of community-based services, with continued promotion of deinstitutionalization. In addition, he points to two other developments that are on the horizon. The first is increasing convergence of mental health policy with those that are the norm in primary care. The second is more meaningful consumer participation in treatment plan participation and choice of professionals and provider organizations.

End of Recession Nowhere in Sight

2009-11-16T13:15:00.005-05:00

The report in USA Today was brief, but its implications leapt off the page for me:

“In the eight states that report monthly tax figures, collections from July through September declined an average of 8.3 percent from a year earlier. Even in places where there's been an income tax increase, such as New York, collections still declined. This comes after there was a 15 percent nationwide drop in tax collections during the first six months of the year.”

With health care in general (and behavioral health and social services in particular) dependent on state financing, I think the ‘end of the recession’ is nowhere in sight – despite the pronouncements of economists. Look for reductions in Medicaid (reduced eligibility, reduced service coverage, reduced provider fees, and more risk-based contracts) and cuts in state-funded services (mental health, addictions, child welfare, juvenile justice, prison health, senior support services, etc.) as the reality of tax collections cause state governments to open up their budgets once again.

If you’re a manager of an organization providing health services or social services – or a county commissioner – the pending tax shortfalls will have the biggest impact on your work. Now would be the time to develop a contingency plan.

For more on planning and managing in these harsh economic times, check out:

Why Do You Need A Mystery Shopping Program? One Word: ACORN

2009-11-09T09:42:00.005-05:00

I've been somewhat bemused by the 'surveillance' film footage of ACORN employees seemingly giving advice on how to evade taxes and conceal criminal activity to conservative activists posing as a pimp and a prostitute.

When I finally saw the entire film footage (on the fabulous "The Daily Show" hosted by Jon Stewart) I was struck with two different thoughts. First, a fleeting thought—I didn't know that people working in the illegal sex trade were concerned about paying taxes. The second, and more substantial thought, is, as an executive of a multi-site organization, how do you know what your front-line team members are doing on most days?

I do feel sorry for the embattled CEO of ACORN. She was making the rounds of the morning talk shows, outraged and threatening to sue because the secret videos broke Maryland law by carrying out an illegal wiretapping operation. But, as many politicians have learned, when the video genie is out of the bottle, no one cares how the video was made. More problematic is that even the most spirited defense of ACORN I've read refers to the organization as "admittedly very poorly managed." Not exactly a glowing endorsement.

So the question is, if your frontline staff were featured in film footage gathered by a hidden camera, what would you see? How do you, as an executive, increase the likelihood that such footage would be benign? There are a few risk management tactics that should be in your organization's plan:

Updated policies and procedures—with testing of staff knowledge of those policies and procedures
Routine assessments with compliance—with policies and procedures across all programs
A consumer 'hotline' (and web site) to report perceived service problems
Related performance metrics on your organizational and supervisory performance dashboards
A mystery shopping program to monitor services from the consumer (and hidden camera) perspective
A robust training and technical assistance program for front-line supervisors

I think the ACORN situation is going to spawn imitators—particularly for health and human services that are perceived as politically unattractive (for any number of reasons). Before your employees are featured on a local news program, be prepared and review your controls for remote staff.

No Person Left Behind: Georgia’s Slippery Slope

2009-11-06T12:25:00.003-05:00

I read not long ago that the State of Georgia is sending released sex offenders to live in a camp in the woods near Marietta, Georgia—even those who own their own homes. There are a myriad of factors that have lead to this situation—zoning laws, parole requirements necessitating these individuals to stay a certain distance from children, and lack of suitable housing (the Associated Press reported that "there is only one homeless shelter in Georgia that fulfils the residency requirements for sex offenders, but it only has two beds, which are usually occupied."). I don't think it's acceptable for our leaders to throw up their hands about the inevitability of this situation, as if they were powerless to effect change.

I find this to be part of a troubling change in our view of the acceptability of treating ‘undesirable’ fellow citizens inhumanely. I think this change in thinking is a threat—a slippery slope in the floor of acceptable treatment—for the consumers we serve. One day it's okay to send people to jail because they have no mental health treatment (they need to exhibit some self control and not act in ways that will land them in jail); the next day it's acceptable to close critical health care services that will result in the death of uninsured persons (who should work hard enough to have insurance); and then we can sentence people (dastardly people who prey on children) to living in encampments without even the human supports of leper colonies of old.

In the behavioral health and social service niche, we serve and advocate for a group of individuals unattractive in popular culture. Runaway teens living on the streets, drug addicts, "the retarded", and more. I caution us all to not stand by when this growing acceptance of inhumanity occurs. For those of you who are not swayed by dewy-eyed humanitarian thinking, you can ponder the immortal words of Ronald Reagan who said, "Protecting the rights of even the least individual among us is basically the only excuse the government has for even existing…”

Can the Hawaii Health Care Experience Be Generalized To All of Us?

2009-11-03T11:52:00.004-05:00

Last month, The New York Times published a piece by Cory Lum on health care policy and financing in Hawaii, “In Hawaii’s Health System, Lessons for Lawmakers” in which Hawaii's system was described. Since 1974, Hawaii has required all employers to provide relatively generous health care benefits to any employee who works 20 hours a week or more. The Hawaii Medical Service Association, the state’s largest insurer—and a Blue Cross Blue Shield member—recently offered the nation’s only statewide system whereby anyone for a nominal fee can talk by telephone or on-line, day or night, to the physician of their choosing.

The article goes on to describe the health care landscape in Hawaii. Hawaii’s health insurance premiums are nearly tied with North Dakota for the lowest in the country, and Medicare costs per beneficiary are the nation’s lowest. Hawaii residents live longer than people in the rest of the country. One example given was that, although Hawaii has the nation’s highest incidence of breast cancer, it has the lowest death rate from the disease.

Are the low health care costs in Hawaii due to mandated coverage? Certainly, the scientist in me agrees you can't conclude that the policy causes the low cost without a rigorous scientifically controlled study. But the seasoned professional in me can 'connect the dots' from universal coverage to better health—and lower cost.

Immigration Detention Policy Changes Bring New Service Opportunities

2009-10-22T08:30:00.003-04:00

Policy shifts in the detention of illegal immigrants could offer new opportunities for behavioral health and social service provider organizations. I read with interest the October 6 report by Dr. Dora Schriro, former Special Advisor on Immigration and Customs Enforcement (ICE) and Detention & Removal, "Immigration Detention Overview and Recommendations," where she announced new recommendations to revamp the currently fragmented, insufficient immigrant detention system. The basis of her recommendations is that using jails and prisons is costly—and often unnecessary—for detention, and that specialized privately-run facilities might be the answer.

In total, the U.S. government spends $2.4 billion annually on its current ‘detention and removal' system. Even a diversion of a small part of that budget for community-based and situation-appropriate settings could be a big opportunity in the field. Some of the specific recommendations that caught my eye include:

Non-governmental organizations and non-profit agencies should be invited to assist eligible individuals in special populations, as well as the general population, to establish community ties and develop viable release plans to qualify for placement in ATD programs
ICE should develop specialized caseloads of aliens including those chronically, medically, or mentally ill or have been detained a significant length of time to improve case management and expedite removal, release, or relief.
More ADA-accessible facilities should be available to house detainees with special needs. Specialists to diagnose and treat each of these populations, specialized case management, and prescription reviews are all needed.
Aliens with mental illness would benefit from improved staffing, appropriate housing, access to step down services, and specialized case management.

You can read more on this in "U.S. Moving Away From Correctional Model for Immigrant Detention; New Ideas Include Expanded Use of Hotels & Nursing Homes." As the plans for restructuring the immigration detention system become more concrete, look to our team at OPEN MINDS for continued coverage of new opportunities.

The Grave Situation at Atlanta's Grady Memorial

2009-10-19T11:11:00.009-04:00

On the board of directors of a health or social service organization? If so, Atlanta’s Grady Memorial Hospital situation is a cautionary tale. A court ruled on September 25th that Grady Memorial—Atlanta's safety net hospital—could close its outpatient dialysis unit. What brought the Grady management team to the place where courts are ruling on its service lines? Consumer desperation, of course.

Grady accepts all patients despite immigration status or ability to pay, and is the ‘last resort’ provider for many uninsured, according to a recent New York Times article. Unfortunately, Grady’s dialysis clinic was projected to lose $2 million this year, and continuing dialysis services was deemed unfeasible. This prompted a lawsuit asking for consumer relief.

The patients’ lawyer, Lindsay R. Jones, called the order Friday by Judge Ural D. Glanville “an angry, punitive decision.” “At least 51 patients had their life support system unplugged today under the authorization of this judge,” Mr. Jones said. In response to the decision, Grady has agreed to pay for up to three months of dialysis at private clinics for the 51 displaced patients. However, the clinic will still close.

The Grady situation is just the first of hundreds of similar situations we are likely to see. The combination of state and local budget deficits—coupled with a likely new range of payer-level health care cost containment measures—will increase pressure on non-profit provider organizations to continue unfunded services.

And don't expect relief from the courts. One quote from Judge Glanville says it all: “As it relates to the receipt of medical treatment, the court is unpersuaded [sic] at this time that plaintiffs have a constitutional right to the sought-after relief."

Word of advice: Understand the cost structure for each service you deliver. Be proactive in seeking additional funding where needed—or in closing those programs you can't afford to continue.

Are You Missing The Market For In-Home Services & Supports?

2009-10-12T20:03:00.006-04:00

The New York Times recently had a piece, "Patient Money: When Elder Care Problems Escalate, You Can Hire an Expert," on the challenges of getting good advice when it comes to caring for elderly parents. The author recommends families hire a geriatric care manager, and adds that

"you must pay these professionals out of your own pocket. Regular insurance does not cover them, although some long-term care policies do. But a good care manager can buy you time and some peace of mind so you can concentrate on your job, your family and your own health."

In addition, the article comes complete with rates—$100 to $200 for consultation; $500 to $1,200 for assessment; and continuing case management by the hour.

I don't see many of the behavioral health and social service organizations I work with preparing to provide in-home support consultations and management needed by an aging U.S. population. There are so many factors that will assure this is a booming market (both private pay and third-party pay, by the way).

We have an aging population, with predictions that the 50+ population will live to 110 years of age(!). There is the push by financially destitute Medicaid programs to keep people at home and out of state-paid nursing homes, coupled with the increasing amount of service cost that consumers and families must pay out-of-pocket. New technologies allow more people with greater levels of disability to live at home. And, we have a changing consumer demographic—a soon-to-be-aging baby boomer population that wants to remain home as long as possible.

Behavioral health and social service provider organizations that give up the market for in-home services and supports for an aging population risk losing the in-home market altogether. Integration isn't a phenomenon limited to physician offices.

Health Reform Made Complicated (And It Is)

2009-10-02T13:30:00.006-04:00

Want a quick summary of the 564 amendments offered to the Senate Finance Committee to 'fix' the Baucus bill?

Timothy Noah and Chris Wilson of Slate.com have done just that. The actual amendments are all described on the Senate Finance Committee's Web site. Unfortunately, they're scattered among six PDF files, and navigating them is a nightmare.

Slate's Chris Wilson assembled all these amendments into a single spreadsheet that can be sorted according to sponsor, party, budgetary offset, and whether the amendment in question addresses insurance coverage, reform of "delivery systems," or financing. (Note: You may need to log into Gmail to view the sortable spreadsheet. A low-fi version is also available.)

Hope you have is much fun with this as I did!

Have You Heard About "FleaHab"?

2009-10-01T11:36:00.005-04:00

Have you heard of FleaHab? It's a new exercise-based recovery program track at the Providence Recovery Center in Santa Cruz, California, run by Darryl “Flea” Virostko, a big wave surfer and three-time Mavericks champion. Now, before you get too cynical about this as another addiction treatment gimmick combining a 'tangential' but attractive consumer activity with the market cache of a noted sports figure, consider the emerging science.

Mr. Virostko hopes that FleaHab will be his anchor in the dry terrain of sobriety. Addicts in the program will replace the high of drugs with the endorphin rush of strenuous physical activity, he says. He recently took a group surfing to try his hand at teaching. “It’s like I’m learning to surf again,” he said. “Seeing them so excited reminds me of when I first started...” according to a quote in "Surfing as Rehab for Those Fighting Addiction".

As you may remember from some of my OPEN MINDS live reporting earlier this summer, I spent a fabulous week at the "State of Mind" conference held at the Chautauqua Institution, where we explored "the techniques and current research findings related to mental health disorders and brain injury..." One big takeaway was learning that there is only one way to generate new brain cells—through extreme physical exercise—and to 'turn them on' requires extreme mental challenges. Another interesting takeaway was that almost all psychotropic medications perform better for consumers when combined with an exercise program. These findings are all the more relevant for consumers who can now use new brain scanning technology to watch their brain change as they recover from mental illness, progress in recovery from their addiction, or work to improve cognitive functioning.

I left my week in New York with some distinct thoughts about the future of behavioral health treatment programs. In a decade, it will likely be considered malpractice to provide behavioral health treatment without a rigorous exercise program. And, the programs that provide consumers access to the technologies that allow them to 'see' their brain recovery are the programs that consumers will select. To that extent, FleaHab is on the right path.

Looking Forward to an End to Safety Net Funding

2009-09-21T10:25:00.008-04:00

Advocates and provider organization management teams are all tracking state budget problems and what they mean for mental health. A few of my colleagues are breathing a sigh of relief because their state budgets left them 'relatively' unscathed. But, for behavioral health and social services, I think the worst budget cuts are yet to come. In 2010, we will have to deal with the effect of the planned state budgets—and probably some mid-year revisions. But, in many jurisdictions, provider organizations will see county and city budgets for these services unravel. On Saturday, ABC news in El Paso, Texas reported that of the El Paso City Council members, four voted to cut ties with the El Paso Mental Health and Mental Retardation agency. Their rationale is that, by law, those services are the responsibility of the county—not the city. ABC-7 reporter Daniel Marin wrote:

"El Paso City Representative Beto O'Rourke says, by law, MHMR is the responsibility of the county. So he along with special city council committee
members… voted to cut ties with the agency…O'Rourke says MHMR's highly publicized funding issues are the result of the old cliché: too many chefs in the mental health care kitchen…"

"MHMR spokesman Rene Hurtado says while every little bit of funding helps, this is all about more than losing the city's $100,000 yearly contribution. "The mental health care system is very complex," said Hurtado. "The more people we have at the table, the better it is for everyone."

"El Paso County Commissioner Anna Perez says, in her opinion, the city has a direct role in helping the city's mentally ill; adding there's too much at stake for city officials to hide behind a law. "[The law] doesn't mean they don't have a place at the table," she said.

The unfortunate reality? Our current systems for mental health treatment, for addiction treatment, for child welfare, and for other social services are strung together with a hodgepodge of federal, state, county, local, grant, donation, and payer dollars. From my perspective, parity and universal coverage can't come too soon. I'll look forward to a time when Americans with behavioral disorders and disabilities are not begging for safety net funding and charitable donations.

"Speed Shrinking" a Possible Avenue for Service Delivery Expansion?

2009-09-09T18:35:00.009-04:00

September 9, 2009

It was inevitable, I guess. Americans want everything in a hurry. And now we've gone from speed dating to speed shrinking. The August 31 edition of The New York Times featured an article, "Answers to Life's Worries, in Three-Minute Bursts". It talks about "speed shrinking gatherings" featuring three-minute sessions for people needing fast advice—or those who find their regular professional on vacation. One interesting comment in the piece was a woman who said it was great to see multiple therapists in short order because “It was a great way to learn which of them I had the most chemistry with.”

What does this mean for the field? For a certain cohort of consumers, 'short sessions' don't seem to be a problem—and viewed as a convenience. And speaking of convenience, I can see the 'speed shrinking sessions' moving from bookstores to on-line meeting places. For professionals in private practice or looking to attract new clients, 'speed shrinking' is a marketing opportunity.

Matrix Mindset, in Australia, for instance, is already capitalizing on this new phenomenon:

Related Resources from the OPEN MINDS Circle Library:

Juvenile Life Imprisonment Flies in the Face of Brain Science

2009-09-03T14:16:00.006-04:00

September 3, 2009

I rarely weigh in on forensic issues in our field; my view is that this is the province of lawyers and politicians. However, I recently received an opinion piece, "Morning Bell: Adult Times for Adult Crimes," from The Heritage Foundation that I couldn’t let pass without comment. The long and the short of The Heritage Foundation position is that the U.S. should not reconsider its policy of sentencing juveniles to life in prison without the possibility of parole. The support for their position is based on a study, "Adult Times for Adult Crimes: Life Without Parole for Juvenile Killers and Violent Teens" by legal scholars Charles D. Stimson and Andrew M. Grossman, of The Heritage Foundation's Center for Legal and Judicial Studies.

To buttress their argument, The Heritage Foundation cites the fact that eleven other countries in the world allow juveniles to be sentenced to life in prison without parole. However, after viewing the United Nations Human Rights Council's 2009 Statement on Juvenile Sentencing (cited in The Heritage Foundation's article), I’m not so sure. The statement includes the following passage, "Eleven countries have laws with the potential to permit the sentencing of child offenders to life without possibility of release: Antigua and Barbuda, Argentina, Australia, Belize, Brunei, Cuba (legislation pending), Dominica, Saint Vincent and the Grenadines, the Solomon Islands, Sri Lanka (legislation pending), and the United States. Currently, there is no evidence of any country, besides the United States, with child offenders sentenced to life without the possibility of release." So much for that evidence.

Some more interesting facts on juvenile life imprisonment come from the same UNHRC statement:

8. The Convention on the Rights of the Child (“CRC”), ratified by every country in the world except the United States and Somalia, codifies an international customary norm of human rights that recommends against life sentences and forbids the sentencing of child offenders to life in prison without possibility of release.14 There are now 135countries that have rejected the sentence through domestic legal commitments and 185 countries that have voted for the resolution in the General Assembly.15 The prohibition, arguably, has now reached the level of a jus cogens norm. As such, it is binding on all states, including those that have not formally ratified it themselves.

10. Customary international law is part of domestic law in the United States and, therefore, juvenile life sentences without the possibility of parole should be prohibited.19 Juvenile life sentences have not been consistently and historically applied. 20 The sentence was not used on a large scale until the 1990s when at least 40 states passed laws increasing the options for sending juveniles to adult courts.21

11. In the United States, there are an estimated 2,484 juveniles serving life sentences without parole. 22 Nationally, 59% of children were sentenced to life without the possibility of release for their first ever criminal conviction. Of these children, 16% were between the ages of 13 and 15 when they committed their crimes, and 26% were sentenced under a felony murder charge, where they did not pull the trigger or carry the weapon.23 In addition, African American youth are disproportionately represented through every stage of the juvenile justice process, including among those children serving life sentences without the possibility of release.24

Regardless of the policies of other countries, the reason for my commentary is that this flies in the face of emerging research on brain development. At this year's Chautauqua Institution, "State of Mind” conference, I attended the update on new brain research from John J. Ratey, Associate Clinical Professor of Psychiatry at Harvard Medical School. One of my takeaways from his update is that new science tells us human brains do not mature until the age of 25 or so. It seems to me that—despite how horrific the crime—to sentence juveniles with not-yet-fully-developed brain functioning to prison sentences with no opportunity for societal repatriation in their later, mature years is indeed cruel and unusual punishment.

Evidence-Based Practices Evolve, But Consumers Are Too Often Left Behind

2009-08-31T15:55:00.010-04:00

August 28, 2009

There is a thought-provoking article that came out in the August 19 edition of the Schizophrenia Bulletin, “Implementing Evidence-Based Practices for People With Schizophrenia,” by Robert E. Drake; Gary R. Bond; and Susan M. Essock. The article is a great summary of the current sad state of the treatment of serious mental illness at the consumer level. Despite significant research on what works, essentially people with serious mental illness are not getting the treatments they need. While the article is a great state-of-the-nation piece, based on our team's work in the public mental health system I think the recommendations need to be expanded.

Over the last decade, a number of systematic efforts to identify evidence-based interventions for individuals with serious mental illnesses have been made. However, although the interventions have been identified, numerous surveys have shown that consumers are not receiving these interventions. The report states:

Epidemiologic data from the National Comorbidity Study in the early 1990s showed that 60% of persons with serious mental illnesses received no treatment in the past year, 25% received clearly inadequate treatment, and only 15% received minimally adequate (far short of evidence-based) treatment.

The 2005 National Survey on Drug Use and Health found that only 8.5% of adults who reported both serious psychological distress and a substance use disorder received any treatment for both problems in the past year.

In their article, the authors recommend solutions that fall in the domains of information technology, state policy interventions, and federal policy interventions. But, I think these recommended solutions will have a limited effect if there are no changes to fundamentals in system design and financing, needed to assure that consumers with mental illnesses can get the services they need. I know the naysayers will contend that there is not enough money in the system to pay for these changes. I would counter that these are not behavioral health system issues. Rather they are health care issues—and these changes would be budget-neutral if we factor in the costs of emergency room visits and hospital readmissions alone.

To view my proposed solutions, check out: http://www.openminds.com/circlehome/circle/content_schizoebpstudy.htm

Technology to Improve Chronic Health Care & Increase Independence

2009-08-24T19:18:00.005-04:00

August 24, 2009

I just finished reading the briefing by Center for Technology and Aging (click to view) about the seven technologies that will improve chronic health care and increase independence. They
list these seven technologies as:

Medication Optimization. Technologies designed to help manage medication information, dispensing, adherence, and tracking.
Remote Patient Monitoring. Technologies designed to manage and monitor a range of health conditions
Assistive Technologies. Devices and equipment that help individuals perform a task or prevent injury.
Remote Training & Supervision. Technologies used to train and supervise health and long-term care workers, and the potential for continuing education and quality assurance.
Disease Management. Patient-centric, coordinated care processes for patients with chronic conditions and conditions that have a significant self-care component.
Cognitive Fitness & Assessment. Technologies that measure cognition or include cognitive practice regimens.
Social Networking. Technologies that enable the building of communities of interest that help older adults communicate, organize, and share with other older adults and care providers.

How will these technologies affect the consumers you serve? This is a great question for your next strategic plan...

Check out some tech-related resources from the OPEN MINDS Circle Industry Library:

New Recovery Program for Net Addicts

2009-08-21T10:48:00.006-04:00

August 21, 2009

In the sea of press releases that I read every day, very few settle into my grey matter. But, today, there was a flash of something happening—though it's a bit early to tell what. The first piece that passed my desk was notice of the first inpatient treatment program for Internet addiction. Just opened outside of Seattle, the reSTART Internet Addiction Recovery Program will help people unplug from the wired world for 45 days for $15,000 (check out their site).

There is nothing particularly new about specialty addiction treatment programs—a quick search of the OPEN MINDS archives and you will find treatment programs for addictions to sex, gambling, shopping, and host of other activities. But, only a few minutes later I was watching a YouTube video from Sony's viral on-line marketing campaign for ending social media addiction. (I was also signing up to learn more about the Social Media Addicts Association.) Trend or data point in the addiction treatment world? Too early to tell.