Given the length of this blog, I’ve divided it into two parts. Part I appears immediately below; Part II will be posted soon.
PART I – WHAT MENTAL HEALTH HOMES ARE AND WHAT THEY’RE NOT
On the ground reality is about to trump rhetoric. Whether you subscribe to my definition of recovery as liberation from the mental health system or SAMHSA’s as the capacity to live a self-directed life, New York’s mental health homes are not intended to promote either. The homes are health care delivery systems whose priority is the same as that for all publicly-funded health and welfare programs throughout the country– state and local governments’ financial survival. At the same time, they offer the promise of effective, integrated and coordinated health care for persons who are poor and designated as disabled. Will they deliver?
INTRODUCTION: THE DOORS OPEN
The State’s first wave of mental health homes, which will comprise the bedrock of its reformed public mental health system, has just received retroactive authorization from the Center for Medicare and Medicaid Services (CMS) to begin operating in New York State effective January 1. The State’s own official start date, its “Phase I” commencement, is February 1 (1). That’s when the first thirteen of these “homes”, actually “integrated care” provider networks linked by common cyber-information systems (Health Information Technology (HIT) networks, in bureaucratese), will begin providing treatment and related services to the residents of ten New York counties who meet the eligibility criteria for serious and persistent mental illness or drug addiction. Hence the designation of the homes as “mental health homes”. Many of these eligible individuals – at least 50% by State estimate — will also be suffering from one or more chronic medical ailments (2,3). “Phase I” will be followed by “Phase II”, affecting sixteen counties, on or about April 1, and then “Phase III”, affecting New York’s remaining thirty-six counties on or about July 1. Sometime thereafter, the two other “disability populations” specified in the Affordable Care Act, popularly referred to as Obamacare, as persons with long-term somatic ailments and those with developmental disabilities, will also receive their care via these health homes or provider networks (4).
In accordance with Obamacare and with the State’s revised Medicaid plan (5), developed to address the State’s budget-busting Medicaid expenditures at the behest of Governor Cuomo, all the homes and their provider networks will be partnered with managed care plans, which will have the responsibility to determine county residents’ eligibility for services and decide whether to reimburse providers for services rendered. Phase I’s thirteen homes/ networks are partnered with nine managed care companies which will compete with one another for enrollees. In the near future, all Medicaid-funded health care in New York, as well as in most States, will be “managed”, with all Medicaid recipients obliged to join a managed care plan of their choosing.
Finally, whatever the future of the Affordable Care Act – whether it’s implemented as is or found to be unconstitutional in whole or in part or is eventually repealed or amended by Congress — health homes are now firmly embedded in Medicaid regulations (6), in synch with the incremental nationwide implementation of health care reform, which does not become fully operative until 2014. As per the Act, states have the option to establish health homes as of January 1, 2011. So far as I know, New York is the third state, behind Missouri and Minnesota, to do so(7,8).More, if not all states can be expected to follow. Comprehensive descriptions of health homes and their attendant regulations are contained in the several documents I reference at the end of this blog(9).
I’m devoting time and space to all this because health homes will be the face of the public health care system in this country for years to come, assuming Obamacare is not overturned. They will also constitute the public mental health system in New York State so long as the Medicaid regulations that authorize them remain in effect. In sum, the homes are likely to impact everyone who reads this blog in one way or another. Their stated intent is to ensure access to integrated care – i.e., one-stop-shopping, or access to both behavioral health and primary health care – for those individuals who historically have been faced with systems barriers to requisite health care; and care that is coordinated – i.e., where all providers involved in a person’s care will know what one another is doing. Perhaps most importantly, at least politically, is that the integration and coordination features of health homes are designed to be cost effective – to save money for local, State and the Federal governments(5,6,9). As you’ll see when I talk about the “Goal Based Quality Measures” for the mental health homes in New York, no mention is made of recovery. Allusions are made by CMS and SAHMSA and in the State’s plan to “… linkage to … supports that promote recovery and resiliency …”, but such linkages are not included in CMS’s or the State’s targeted outcomes, designated in officialese as “goal-based quality measures”(6,10,11). After all, New York State’s constitution obliges State government to provide care for persons considered seriously mentally ill, with no stipulation as to the kind of care to be provided. That interpretation has been left to each succeeding generation of policy makers and politicians to decide. And while Cuomo has endorsed the concept of “integrated care” for persons with presumed disabilities – c.f. my last blog on this site and Cuomo’s support for the development of community-based services that conform to the Olmstead decision – his most pressing concern as well as responsibility is to ensure the solvency of State government (12).
Recovery and services that promote the rehabilitation of persons considered seriously mentally will remain under the purview of the New York State Office of Mental Health. As per its 2009 “Patient Characteristics Survey”, approximately 10% of the nearly 90,000 persons enrolled in its out-patient programs participated in recovery and rehab-oriented programs (13,14). Again, the health homes are a new medical care delivery system, firmly embedded in the biomedical model. They are under the fiscal jurisdiction of the State’s Department of Health, which oversees State Medicaid expenditures and is the governmental entity that negotiates with the Center for Medicare and Medicaid Services (CMS), the Federal regulatory agency, for the approval of new State Medicaid initiatives. In order to comply with CMS’s rules governing health homes, New York State’s health homes plan must pursue three primary goals: improving health care recipients’ “experience of care”; improving their health; and reducing per capita health care costs. It must also endorse several key practice principles that will underpin the plan: an holistic orientation of care; coordinated and integrated care; enhanced access to care; quality assurance and participants’ safety; and payment commensurate with services rendered. Finally, persons eligible for enrollment in a health home must have at least one chronic medical ailment, including a serious mental illness or a substance abuse disorder. As the financial carrot to induce the states to undertake the foregoing, CMS will authorize a Medicaid reimbursement rate (FMAP) to participating states of 90% — up from the usual 50% — for the first two years of program operation (3,6). (Ironically, 26 states have brought suit against the ACA, with the Supreme Court expected to hear arguments pro and con in May, declaring the Medicaid expansion crucial to ACA unconstitutional and this financial incentive “coercive”. Everything appears to be on the line.)
ORIGINS: HISTORY AND IDEOLOGY
Just to provide a bit of history about the homes, courtesy of the National Council for Community Behavioral Healthcare, health homes have their antecedent in “medical homes”, first developed over twenty years ago to address the complex medical issues presented by chronically ill children. Over time, the medical home evolved to signify a team or interdisciplinary approach to the provision of primary care for all persons with chronic medical conditions, and many states currently operate them. “Health home” is the appellation eventually utilized in the Affordable Care Act (16). Major impetus to integrate behavioral health and primary health care came with the 2006 publication of the landmark, sixteen-state study undertaken by the National Association of State Mental Health Program Directors (NASMHPD), “Morbidity and Mortality in People with Serious Mental Illness,” which raised the alarm at the study’s chief finding, that “Persons with serious mental illness die, on average, 25 years earlier than the general population (17).” The study’s Executive Summary went on to state that “… 60% of premature deaths are due to medical conditions such as cardiovascular, pulmonary and infectious diseases. People with serious mental illness also suffer from a high prevalence of modifiable risk factors, in particular obesity and tobacco use …” As for possible causes, the Summary underscored, among several, “Lack of access to appropriate health care and lack of coordination between mental health and general health care providers.
Closer to home, in articles published in 2009 and 2010, Mike Hogan, New York’s Commissioner of Mental Health, and Lloyd Sederer, his Medical Director, argued for the inclusion of behavioral health in the health homes that were to be a key component of the Affordable Care Act (18,19). They pointed out that as many as 60% of adults receive treatment for mental illness – essentially prescriptions for SSRIs – from primary care physicians, who often feel ill-equipped to do so. Further, persons diagnosed with serious mental illness have high rates of co-morbid medical problems. New York’s most recent “Patient Characteristic Survey” (2009) posted on its State Office of Mental Health (SOMH) website revealed that 50% of all persons who received State or Medicaid-funded services had at least one chronic medical ailment, with half of that number suffering from cardiac disease (20). In health care surveys I conducted from 2006-8 in the case management programs I directed in New York City, half of our 700 clients, all diagnosed with serious mental illnesses, also had chronic medical ailments, with, again, half of that number suffering from metabolic illnesses, principally diabetes and heart disease. More dramatically, our clients’ death rate from cardiac illness – 1.9 per 100 persons – during 2007-9 almost matched that uncovered by the NASMHPD survey – 2.3 per 100 persons – in 2006 and nearly quadrupled the U.S. incidence — .525 per 100 – in 2004 (17,21).
The rationale for mental health homes seems readily apparent to me. In an eighteen-month long three-study we conducted from 2008-10, largely inspired by the NASMHPD study and by our clients’ increasing death rate, we tracked for one year the health care experiences of 100 clients we had trained, conjointly with 50 case manager counterparts, as health care advocates. (C.F. “Ask Questions … Get Answers II — Training Behavioral Health Consumers and Case Managers as Co-Equal Primary Health Care Advocates: Summary of A Comparative Study, September, 2008 – March, 2010”, referenced below .) We had several objectives: first and principally, to have clients and case managers work collaboratively, with the clients taking the lead, to improve clients’ access to primary health care; then, to have these informed clients press both their primary care physicians and psychiatrists to monitor their metabolic signs for abnormalities; in which event, to press their providers to take appropriate action, including the lowering of prescribed dosages of atypical anti-psychotics, which had been implicated in the NASMHPD study as one of the factors causing its subjects’ increase in mortality; and finally, to persuade their primary care physicians and psychiatrists to communicate readily with one another and so coordinate their care. The outcomes, based on client self-report and case manager observations, were uniformly positive, with clients, corroborated by their case managers, reporting improved access to health care, improved personal health and satisfaction with their health care providers. With equal uniformity, however, they also reported an inability to get primary care physicians and psychiatrists to communicate with one another. The latter, anecdotally, were less amenable to contact their primary care counterparts, and it fell to the clients and/or their case managers to carry pertinent medical information between the two. We concluded, I believe correctly, that this was a systems issue and beyond the capacity of a single case management program to affect.
Health homes offer the promise of bridging this barrier to effective and coordinated care. Those targeted for enrollment in New York are the almost 1 million current Medicaid enrollees identified in the State plan submitted to CMS “ … as high cost/high need enrollees with two or more chronic conditions and/or a Serious Persistent Mental Illness…”(3). The “chronic conditions” prioritized in the State plan, after serious mental illness and substance abuse disorders, are asthma, diabetes, heart disease and obesity, the latter three the metabolic disorders linked to the decrease in life expectancy for persons diagnosed with serious mental illness. Given my nearly twenty years experience grappling with the fundamental case management issue of care coordination or securing the cooperation of other providers, I am skeptical about the homes’ ultimate effectiveness unless they address the several caveats I’ll posit in this blog. Before I enter that discussion, I’ll describe the composition of the provider network that will comprise the health home that will serve the western half of Brooklyn, an area that fronts New York harbor and has about one million residents, and where I’ve lived and worked for the past 40 years. I’ll also outline the contradictions that I believe the home’s providers will have to confront; hypothesize probable outcomes; and suggest the steps – guerilla tactics I’ll call them – that I would and they could take to address my hypothesized issues.
WEST BROOKLYN MENTAL HEALTH HOME (1)
I know the providers firsthand, since the first steps to establish the provider network – a common electronic health record and information system — were being discussed by the prospective providers when I retired and left the case management program I had directed for seventeen years. The lead provider is a large private voluntary hospital, where I began my career in public mental health forty years ago and where I worked for almost twenty years. It has as an important partner a second large private voluntary hospital that houses the largest Federally-funded family health care center in New York state. Both hospitals also operate psychiatric in-patient units that accept emergency admissions, known in New York as 9.39 hospitals. The seven remaining providers are large mental health/multi-service community-based agencies that operate between them three large case or care management programs, one of which is the program I directed; three large mental health housing programs; and several outpatient treatment programs. Since the geographic area this home will serve contains a large population of potentially eligible enrollees, its provider network will be among the largest in the State.
The fundamental problem affecting this home as well as all the others is its top-down, authoritarian organization and the likely infringement on enrollees’ treatment choices. I’m referring to enrollees’ choice of treatment vs. no treatment, particularly as regards psychiatric care. Of course, the lead provider, as with six of the other Phase I homes, is a hospital, so what else would you expect but a feudal organizational culture. (It should be noted that the remaining six homes also have at least one hospital in their provider networks. It can be assumed that all future health homes will have similar network configurations.) But I really have in mind the total institution, the old State hospital, that the homes are actually replacing, which is why I called the homes “hospitals without walls” when I first wrote about them this past September (23). Their three primary goals are to reduce acute inpatient hospitalizations and emergency room utilization and to secure treatment compliance, particularly as regards medication (3). That last goal immediately calls to mind a blog posted by Giannakali on her Beyond Meds website a week or so ago: “Medical compliance? Adherence? Screw that. My MDs are my PARTNERS” (caps hers) (24). That says it all for me.
The State – all states – has been attempting to reduce in-patient stays in psychiatric units since it began emptying out its large institutions. When the State’s Intensive Case Management program was launched 1988, that was its stated goal and its targeted clients were the those persons considered the “heavy users” of psych hospital and ER services, i.e., those 10% who were responsible for 90% of the State’s psych Medicaid outlay. Those are precisely the same persons – or at least the same identifiers – being targeted today. In truth, the State has achieved some success: 66,000 persons were hospitalized in State or general psych hospitals in 2001, with 60% or 39,000 re-hospitalized within 6 months, reduced to 28,000 persons hospitalized in 2009, with 15,000 or 55% re-admission within 6 months (20,25). Now, of course, it’s taking on a larger goal, the reduction of all in-patient stays, including those due to physical illnesses or injuries. A laudable goal, since the stated intent is to reduce hospitalizations that effective out-patient care will make “avoidable”. The question – and problem – is how that goal is to be achieved.
END OF PART I. IN THE SECOND PART OF THIS POST, I WILL LOOK AT THE ISSUES THAT NEED TO BE ADDRESSED, AND STRATEGIES FOR DOING SO.
1.- NYS Department of Health (DOH), “Overall Rollout Plan,” January 27, 2012, http://www.health.ny.gov/health_care/medicaid/program/medicaid_health_ homes/nys_implementation.htm
2.- NYSDOH, “Chartbook on Disability in New York State, 2006,” Disability and Health Program, http://www.health.ny.gov
3.- NYSDOH, “NYS Health Home SPA for Individuals with Chronic Behavioral and Medical Health Conditions – SPA # 11-56,” September 28, 2011, http://www.health.ny.gov
4.- Social Security Administration, “State Option to Provide Coordinated Care Through a Health Home for Individuals with Chronic Conditions,” http://www.ssa.gov/OP_Home/ssact/title19/1945.htm#ftn490
5.- NYS Office of Mental Health (NYSOMH), “Statewide Comprehensive Plan 2011-2015, Chapter 3, Redesigning Medicaid Health Care in New York State,” October 1, 2010, http://www.omh.state.ny.us/
6.- U.S. Department of Health & Human Services, Centers for Medicare & Medicaid Services (CMS), “Health Homes for Enrollees with Chronic Conditions,” November 16, 2010
7.- Minnesota Department of Health, “Health Reform Minnesota: HCH I Health Care Homes,” January 30, 2012, http://www.health.state.mn.us
8.- Open Minds, “Missouri Health Homes Launched January 1, 2012,” January 9, 2012, www.openminds.com
9.- Henry J. Kaiser Family Foundation, “Medicaid’s New ‘Health Home’ Oprtion, January, 2011, www.kff.org
10.- Substance Abuse and Mental Health Services Administration (SAMHSA), SAMHSA Blog, “What is a Health Home,” January 30, 2012, http://blog.samhsa.gov
11.- NYSDOH, “The Quality Measures for Health Homes,” January 30, 2012, http://health.ny.gov/health_care
12.- Carney, J., “More on Recovery & Liberation …”, January 26, 2012, www.madinamerica.com
13.- NYSOMH, “Patient Characteristics Survey, 2007,” http://www.omh.state.ny.us/
14.- NYSOMH, “Personalized Recovery Oriented Services (PROS), http://www.omh.state.ny.us/
15.- Bazelon Center for Mental Health Law, “Amicus Brief in U.S. Supreme Court Defending the Affordable Care Act’s Medicaid Expansion,” February 2, 2012, www.bazelon.org
16.- National Council for Community Behavioral Healthcare, “Partnering with Health Homes and Accountable Care Organizations: Considerations for Mental Health and Substance Use Providers,” January, 2011, http://www.uclaisap.org/Affordable-Care-Act/
17.- National Association of State Mental Health Program Directors (NASMHPD), “Morbidity and Mortality in People with Serious Mental Illness,” October, 2006, www.nasmhpd.org
18.- Smith, T.E., Sederer, L.I., “A New Kind of Homelessness for Individuals with Serious Mental Illness? The Need for a ‘Mental Health Home’,” Psychiatric Services, April, 2009, Vol. 60, #4, pp. 528-33
19.- Hogan, M., Sederer, L.I., Smith, T.E., Nossel, I.R., “Making Room for Mental Health in the Medical Home,” Preventing Chronic Disease, November, 2010
20.- NYSOMH, “Patient Characteristics Survey, 2009,” http://www.omh.state.ny.us/
21.- Carney, J., “Ask Questions … Get Answers: Final Outcomes …”, Powerpoint Presentation, September 22, 2010
22.- Carney, J., “Ask Questions … Get Answers, II – Training Behavioral Health Consumers and Case Managers as Co-Equal Primary Health Care Advocates: Summary of a Comparative Study, September, 2008 – March, 2010,” October 6, 2010 & February 2, 2011, www.behavioral.net
23.- Carney, J., “Mental Health Homes as Hospitals Without Walls: New York State’s Mental Health System Reform,” September 1, 2011, www.behavioral.net
24.- Gianakali, “Medical Compliance? Adherence? Screw That. My MDs Are My Partners,” January 30, 2012, http://beyondmeds.com
25.- NYS Office of Mental Health (NYSOMH), “Statewide Comprehensive Plan 2004, Chapter 4, Utilization of Inpatient Beds,” http://www.omh.state.ny.us/