It’s commonplace to hear that we need a big change—a revolution, if you will—to make “the system” recovery-oriented, to replace the tired old over-emphasis on a biological model and to replace it with a new more hopeful standard of care. I know—I have used all these catchwords myself for the past several years.
I know too that there are great controversies and strongly held differences of opinion among us about whether significant change can happen and whether it will ultimately be grassroots or top-down. I don’t pretend to know the answer to whether or how it may happen—though I suspect it will be some of each. But I can’t really accept that nothing will change and that I should go off and just pursue my hobby of taking photographs of the beauty in landscapes. I do know I would keep up the grassroots re-education work of the Mad in America Continuing Education Project because this kind of field work is going to be essential to changing the standard of practice, no matter what the larger systems issue look like.
For the sake of argument and showing how a more top-down strategy would look, I will describe 5 C’s and how they would be essential elements of that strategy.
Before going further, I would like to differentiate between the two largely separate systems of care in mental health — the private and the public. Full disclosure requires me to admit that my professional experience has been primarily in the public system for about 35 years, 20 of them in administrative leadership roles at the state level. Most instructive were my nearly six years as a state mental health and addictions commissioner in the early to mid-2000s. Therefore, I will concentrate my thoughts and suggestions on the world of publicly funded programs—all the way from prevention and early intervention to state hospitals and everything in between. For now I’m going to focus on what I know best and leave the private insurance and private pay world for another time.
The first thing to understand about public mental health and addictions is that the world is highly politicized with many competing and contradictory forces at work. Much of the funding environment is concentrated on fiscal and public safety risks. Just getting attention for mental health outside a major crisis is an achievement in itself. These forces operate at several levels—community mental health “authorities” with local elected officials often involved along with a myriad of advisory committees, councils and boards. At the state level, the input is gathered again from relationships with community and hospital providers. It is sometimes gathered from “consumer” councils and almost always from personal and professional relationships that condition everything that happens.
Ultimately, the state legislators make the key decisions with lobbyists and bureaucrats because the buck stops with them for funding their state’s services. This all goes back historically to the veto by President Franklin Pierce of a land grant bill passed by both houses of Congress in1854 that would have established the federal government as the funder of state insane asylums—which is just a background topic for another time. The important point is that, while federal Medicaid funds are a major, if not the major source of funding for community mental health services, the states must still pony up their own funds — usually around 60% — in order to get a share of the federal funds.
Now, it’s all a lot more complicated than this and there are other players (such as major metropolitan areas and relative newcomers like accountable care organizations that are totally distracted by demands to “integrate” mental health and health care services) and some federal initiatives (like the Murphy bill) that can create more dynamics, havoc and targets for change.
Two key characteristics of public mental health systems are these:
- The predominance of Medicaid funding means that a good portion of the services are, by definition, based on the medical model. And
- psychiatric medications are a major but hidden cost driver. I’ve written elsewhere about the $200-300 million cost of psychiatric medications that were over and above the $500 million budget I had in a small state like Oregon. The pharmaceutical lobby has convinced this legislature and most others to separate these funds from the rest of the Medicaid budget so that they are uncontrolled expenditures.
Our work is cut out for us. This is not for the faint of heart or the totally inexperienced.
With all that as background, I can tell you that the first step in a process of pubic system change is Commitment. There is an extraordinary amount of work that needs to be accomplished and there will be resistance of many kinds — the inertia of decades of the old model, professional and cultural resistance, political push back from the usual suspects in nice suits, layers of accumulated administrative procedures, and the indifference and stigma that accompany efforts at the legislative level. And commitment will have to be developed with the expectation that whoever is the state’s mental health commissioner — ideally someone you’ve enlisted as a change agent — will not likely be there more than about 2 years later. For example, when I left my position in 2008 and looked at the list of the 50 commissioners in 2011, only 3 were left who I’d worked with during my tenure.
The second C is Courage. For obvious reasons, the shots will start being fired at the kinds of changes that will be needed. All the accusations that we already hear will come out in megaphone style — you’re antipsychiatry, you’re anti-medication, you’re Scientologists, you’re tilting at windmills, you’re going to get fired and on and on.
Third, this kind of system change will require Creativity to design a credible plan. The plan should look something like this: The state mental health department will take control of the budget for psychiatric drugs and reduce the unnecessary and unproductive use of these drugs. The plan would commit to improving outcomes like reducing inpatient costs, improving functional outcomes — people doing better with work, school and social lives — all quite measurable. In order to do this, a large portion of estimated medication cost savings would be reinvested in things that work — peer supports, housing, improved psychosocial interventions that have unbiased research to support their effectiveness. To sweeten the pot, the plan could offer up a portion of the cost savings from reduced medication use to meet other state budget needs.
Opportunities will present themselves for change — a major budget crisis is one of the best because it gives one an open window to airing out the fiscal costs of business as usual. As I noted above, the cost of the psychiatric drugs themselves is a major cost driver. It would be critical at the outset to have an accurate assessment of the costs of psychiatric medications, whether they Medicaid funds or other funds. To get there may require using public information request procedures — that’s what they are there for. And then to point out that all the available research shows that outcomes are worse when people are on multiple drugs at high dosages for long periods of time.
The budget cycle is one that requires a careful analysis of these kinds of costs and then a viable budget proposal that has to be vetted at several levels. The plan must take into account how all the other funds are allocated — do they go to providers directly or are there layers of intermediaries like local government, accountable care organizations or hospitals or combinations of all these? Who are the players who will be in a position to implement changes? The more that all the potential partners are involved and the fewer surprises involved, the better.
A creative plan will look at all the types of funding available (state General Fund, Medicaid, local funding if any, grants, etc.) and understand where there is flexibility and where there isn’t. As noted already, a key feature of a plan will be to reduce the wasteful funding of psychiatric drugs and not lose the funds (at least all of them) to budget deficits that the state has to make up for because of poorer revenue forecasts or whatever drives budget problems. Part of the plan must be to specify which non-drug services and supports are needed as more humane and cost effective alternatives to the current paradigm of care. Many of these services may already be in place, some may need to be created. All of these considerations must be woven into a coherent program and budget proposal.
This leads to the fourth C — Capability. What I’ve described in terms of insider processes will require real knowledge, skills and abilities. Good intentions and abstractions are fine but won’t complete this kind of work. Technical skills in writing proposals, doing fiscal analysis, and being able to explain the plan in largely layman’s terms are required. A resource that is often overlooked but might make all the difference is that of people who have worked in the system but who are no longer bound to it — retirees are often wasted resources. Many of us had our hands (and sometimes our minds) tied and still want to make a difference. We can serve as consultants, drafters of budget and program proposals, critical reviewers, and networkers with key players still working in the system. Many of us know how to do such distasteful things as writing policies and administrative rules. These will all be necessary parts of an inside systems change. One other essential capability will be to find and engage partners in the process – progressive psychiatrists, mental health administrators who have begun to understand the need for better outcomes, really good budget analysts, peers and other advocates for change, service providers who can speak to the need for more services as alternatives to over-medicating people, and a few legislators who can champion a challenging political battle.
Finally, the process must be managed with Careful attention to the risks involved. Whatever plan is created to assist with the reduction in use of psychiatric medications has to be crafted with great care and attention to the risks in drug withdrawal or reduction protocols, informed consent procedures, fearless critical incident reporting and analysis, and data collection for evaluating progress. Acknowledging the risks up front is important even as the risks of continuing business as usual is highlighted as part of the need to change. We already know that the risks we’re taking now in terms of human suffering and poor outcomes and out-of-control costs outweigh the risks we would be assuming. Ultimately, a retooling of the system is going to require careful attention to training and educating existing and new staff.
Maybe this is discouraging to contemplate. Maybe grassroots is the better option, but this initial shot at what’s involved in organizational system change is intended to jump-start a conversation about what is likely to be involved. I would invite any and all comments to what I’ve outlined.