Psychiatry and Primary Care Integration: Policy Implications

Transcription

1 Psychiatry and Primary Care Integration: Policy Implications School of Medicine and Health Sciences School of Public Health and Health Services The George Washington University Washington, D.C.

2 Strengths World-leading medical research institutions Extensive network of medical/academic centers Well-trained medical/health personnel Existing models of medical information technology Generous health care expenditures: $2.1 trillion (~$7,000/person/year; 15% of GNP) FEHB program, Medicare, Medicaid, Massachusetts and Oregon models, VA universal care for select American populations

3 Weaknesses American health system s fragmentation No basic health care package for all Americans 15% of Americans uninsured (~ 46 million) ~ 57 million Americans struggle to pay their medical bills Medical bills are one of the leading causes of bankruptcies Inadequate human resources primary care physicians, nurses, physicians assistants, others High debt levels of graduating health care professionals

4 Weaknesses, continued We spend: American health care expenditures: $2.1 trillion (~ $7,000/person/year; 15% of GNP) We get: U.S. ranks 42 nd in the world for life expectancy Approximately 30% of all health care dollars go to profit and overhead insurance companies, health corporations Americans medication costs are much higher than other nations

5 Weaknesses, continued High health care costs undermine American business s global competitiveness Minimal or no health promotion/illness prevention Emergency Rooms are the treatment venue of choice for uninsured Americans Expensive, discontinuous, inefficient, ineffective 18,000 Americans die each year because they have no health insurance

6 Weaknesses, continued (access) 2/3 of primary care physicians could not get out-patient mental health services for their patients ( ) A rate twice as high as for other services Shortages of mental health care providers Health plan barriers Lack of coverage or inadequate mental health coverage Fewer than 40% of those who need the care receive it Mental health parity necessary but insufficient to eradicate lack of access to mental health care

7 Weaknesses, continued (quality & finances) PCPs treat more psychiatric patients than psychiatrists (2:1) 12% of those patients receive minimally adequate care 4 medication checks and 8 psychotherapy visits per year Psychiatric physicians are paid less than other physicians for virtually same O.P. services Of Medicare allowable rates, other physicians were paid 116.6% for typical E & M visits Psychiatric physicians paid 96.8% (within managed care networks)

8 Lessons Learned Most high-income nations: Spend 7-10% of GNP on health care Spend 10-12% on overhead Medicare overhead is less than 5% U.S. health corporations overhead and profit aggregate: ~30% US Health insurance premiums up ~ 87% since 2000

9 Lessons Learned, continued High-income nations health care systems essentials: Universality (all residents are covered) Accessibility (access to care is a right) Comprehensiveness (no discrimination against pre-existing conditions) Transferability/portability Single payer Private option available (15-18% of populations add private option) Health systems observatory- assessing performance

10 Challenges & Opportunities Transforming America s health system Incentives, innovations, psychiatry and primary care integration Universal health care for all Americans Apply Lessons Learned: our experiences and other nations The medical home integrate primary care, mental health, and public health, health promotion/illness prevention Standardize electronic medical records (EMR) across the system Provide financial and human resources for EMR implementation and portability Implement telemedicine programs, now sanctioned by law in twelve states and required of health insurance programs to do so

11 Challenges & Opportunities, continued Transforming America s health system Incentives, innovations, psychiatry and primary care integration Consider economies of scale regarding purchases, payments, and health services administration Incentives for promoting and adopting health adaptive behaviors Consider all determinants of health-bio-psychosocial Provide incentives for medical education innovations, health team teaching, health services management research, treatment outcomes, and the use of information technology in all Education debt relief for all medical/health professions, through public service, tax relief, and/or other means

12 Challenges & Opportunities, continued Transforming America s health system Incentives, innovations, psychiatry and primary care integration Integrate evidence, ethics, and health policy Review, with regularity, health system s performance through internationally-accepted indices of populations health Provide incentives for meeting and surpassing such indices Establish a health systems observatory for on-going system s performance monitoring clinically, financially, and ethically Crossectorally, health in all policies Hemispheric and Global Health partnerships

13 Challenges & Opportunities, continued Transforming America s health system Incentives, innovations, psychiatry and primary care integration Flexner Report at 100, medical team training for the 21 st Century Knowledge competencies shared goals and objectives Skill competencies team membership & leadership Attitude competencies shared vision/mission, collective efficacy In a medical home context Evolving 21 st century health care systems

14 Challenges & Opportunities, continued Transforming America s health system Incentives, innovations, psychiatry and primary care integration The Medical Home a person who serves as trusted advisor and caregiver, supported by a coordinated/integrated team- originated in 1967 Promotes prevention, provides care Coordinates care with other caregivers and community resources Integrates care across the health system Care and health education provided, culturally competent In the context of family and community

15 Challenges & Opportunities, continued Transforming America s health system Incentives, innovations, psychiatry and primary care integration Medical Home (continued) Further research necessary Measure core function of medical home Develop evidence base for how model best implemented Payments reward prevention, care, and care coordination/integration Caregivers trained to understand and enact medical home model as part of a team

16 Challenges & Opportunities, continued Medical Home, continued 50% of psychiatric disorders by age 14, 75% by age 24 Pediatrics & primary care relevant High levels of depression comorbidity with cardiovascular disease, diabetes, other medical conditions 30%-60% prevalence in inpatient medical settings 20% prevalence in outpatient settings Severely mentally ill, high prevalence of diabetes, cardiovascular diseases, twenty five years earlier mortality

17 Challenges & Opportunities, continued Medical Home, continued Include psychiatry in medical home pilot/demonstration projects Primary care medical homes, severely mentally ill homes Involvement in clinical & management leadership Access, quality, outcomes, finances ongoing assessment Performance of individual caregivers, teams, systems Locally, regionally, nationally Combined focus on individuals, families and populations health Compare outcomes, nationally & internationally New learning, thinking, acting through continuing education Incentives for caregivers and receivers for positive change

18 References Kessler, R., et al., National Comorbidity Survey- Replication, in Archives of General Psychiatry, volume 62, pp (June 2005) Figueras, J., et al., Health Systems, Health, and Wealth: Assessing the Case for Investing in Health Systems, World Health Organization, European Ministerial Meeting, Tallinn, Estonia (June 2008) Sorel, E., Transforming America s Health System, Obama Health Reform Discussion Group, Washington, D.C. (December 2008). Sorel, E., Psychiatry & Primary Integration Across the Lifespan, APA Assembly, New Orleans, May 2010 Morrison,. G., et al., Team Training of Medical Students in the 21sat Century: Would Flexner Approve? in Academic Medicine, volume 85, number 2, pp (February 2010) AAMC, The Medical Home: AAMC Position Statement, Washington, D.C. (March 2008)