Why Now Is the Right Why Now Is the Right Time to Work TogetherTime to Work Together

Collaborative Family Healthcare Collaborative Family Healthcare AssociationAssociation

1010thth Annual Conference Annual Conference

DenverDenver

November 6, 2008November 6, 2008

What We’ll Do This EveningWhat We’ll Do This Evening

• We’ll review what we know about-- We’ll review what we know about-- neuroscience, why we die prematurely, neuroscience, why we die prematurely, primary care, pertinent health professions primary care, pertinent health professions workforce, and health care expenditures.workforce, and health care expenditures.

• Do the assignment: i.e. Answer the Do the assignment: i.e. Answer the question.question.

• Plea for Plea for actionaction now, using what we know. now, using what we know.

We Know Why We Die We Know Why We Die PrematurelyPrematurely

40%40% Our behaviorsOur behaviors

30%30% Our geneticsOur genetics

15%15% Our socioeconomic statusOur socioeconomic status

10%10% Shortfalls in medical careShortfalls in medical care

5%5% EnvironmentEnvironment

We KnowWe Know

► A person with a serious “mental health” A person with a serious “mental health” problem, on average, dies 25 years sooner problem, on average, dies 25 years sooner than other persons, at least in part because than other persons, at least in part because of a lack of clinical care. of a lack of clinical care.

► A large portion of care for a person with A large portion of care for a person with mental health and/or substance use problems mental health and/or substance use problems occurs in primary care settings, or not at all. occurs in primary care settings, or not at all.

► The US has a system of health care that The US has a system of health care that emphasizes medical subspecialism in emphasizes medical subspecialism in preference to primary care, public health, preference to primary care, public health, and mental health.and mental health.

USA Primary Care USA Primary Care PerspectivePerspective

A Primary Care Perspective:A Primary Care Perspective:The 2000 EcologyThe 2000 Ecology

We Also Know: We Also Know: Primary Care Improves Primary Care Improves

Population Health Outcomes Population Health Outcomes

► Generic outcomes are better in Generic outcomes are better in systems with stronger primary care systems with stronger primary care (no study shows otherwise).(no study shows otherwise).

► Primary care improves effectiveness.Primary care improves effectiveness.► Primary care improves efficiency.Primary care improves efficiency.► Primary care improves equity.Primary care improves equity.

Currently in Toxic Currently in Toxic EnvironmentEnvironment

►No nationally recognized role in No nationally recognized role in health care.health care.

► Insufficient technology.Insufficient technology.►Horrible business model.Horrible business model.►Main effects compromise prevailing Main effects compromise prevailing

US paradigm of wealthcare.US paradigm of wealthcare.►Erosion of comprehensiveness.Erosion of comprehensiveness.►Segregation of so-called mental and Segregation of so-called mental and

physical health.physical health.

Direct Patient Care Physicians Direct Patient Care Physicians (MD&DO)(MD&DO)

FPFP FP & FP & GPGP

PCPC Not Not PCPC

TotalTotal

19911991 45,3545,3555

67,0767,0788

156,2156,29191

294,14294,1477

450,4450,43838

20012001 67,8667,8600

85,6585,6566

204,0204,06868

370,67370,6788

574,7574,74646

20062006 83,0083,0022

97,1397,1344

237,5237,50606

434,92434,9222

672,4672,42828

1991-1991-20062006

+83%+83% +45%+45% +52%+52% +48%+48% +49%+49%

Population growth 1991-2006 = 19%

Primary Care Workforce Sept Primary Care Workforce Sept 2007 2007

►97,752 family physicians/general 97,752 family physicians/general practitioners (1 for every 3, 081 persons; practitioners (1 for every 3, 081 persons; 14.4% of the physician workforce).14.4% of the physician workforce).

►92,257 general internists (1 per 2,443 92,257 general internists (1 per 2,443 adults) and 48,930 general pediatricians adults) and 48,930 general pediatricians (1 for 1,548 children and adolescents).(1 for 1,548 children and adolescents).

►238,939 primary care physicians (1 for 238,939 primary care physicians (1 for every 1,260 persons).every 1,260 persons).

Nurse Practitioners and Physicians Nurse Practitioners and Physicians AssistantsAssistants

►The number of nurse practitioners grew The number of nurse practitioners grew 120% to 155,990 between 1996 and 120% to 155,990 between 1996 and 2004. Upwards of 80% were practicing in 2004. Upwards of 80% were practicing in primary care in 2000.primary care in 2000.

►The number of physician assistants grew The number of physician assistants grew 160% between 1996 and 2007, to 160% between 1996 and 2007, to 69,473. Only one-third (34%) practice in 69,473. Only one-third (34%) practice in primary care, down from half a decade primary care, down from half a decade earlier.earlier.

PsychologistsPsychologists

►Of about 102,000 PhD psychologists, Of about 102,000 PhD psychologists, approximately 91,400 are employed, approximately 91,400 are employed, 70,300 or so full time. 70,300 or so full time.

►3% Annual growth rate in workforce.3% Annual growth rate in workforce.►APA estimates there are about 31,500 APA estimates there are about 31,500

licensed clinical psychologists.licensed clinical psychologists.► In 2006, there were about 3600 PhD’s In 2006, there were about 3600 PhD’s

awarded and about 1500 PsyD’s.awarded and about 1500 PsyD’s.

PsychiatristsPsychiatrists

►Around 1980 GMENAC estimated a Around 1980 GMENAC estimated a need for 15.4 psychiatrists per 100,000 need for 15.4 psychiatrists per 100,000 people.people.

► In 2000 there were about 45,600 In 2000 there were about 45,600 psychiatrists (about 39,400 adult) psychiatrists (about 39,400 adult) representing about 16.5/100,000.representing about 16.5/100,000.

►The March 2008 psychiatry match The March 2008 psychiatry match resulted in 1013 psychiatry categorical resulted in 1013 psychiatry categorical residents.residents.

Social WorkersSocial Workers

►More than 600,000 people hold a social More than 600,000 people hold a social work degree.work degree.

►A masters in social work is the predominant A masters in social work is the predominant degree for licensed social workers (79%).degree for licensed social workers (79%).

►Almost 50% of the National Association of Almost 50% of the National Association of Social Workers 2008 membership survey Social Workers 2008 membership survey respondents identified mental health or respondents identified mental health or health care as their primary area of health care as their primary area of practice.practice.

WHEW!!WHEW!!

There’s a lot of folks foraging in our There’s a lot of folks foraging in our landscape!landscape!

Health Care SpendingHealth Care Spending

►16% of the US Economy 16% of the US Economy

BUTBUT

►From 2000 – 2005 healthcare From 2000 – 2005 healthcare devoured nearly devoured nearly 25%25% of our of our Economic GrowthEconomic Growth

Health Care ExpensesHealth Care Expenses

Health

Education

Defense

Unadjusted Expenditures Unadjusted Expenditures 2005 vs. 1970:2005 vs. 1970:

► 26x’s expenditures for personal health care26x’s expenditures for personal health care

► 18x’s national health care expenditures per capita18x’s national health care expenditures per capita

► 30x’s for physician services 30x’s for physician services

► 37x’s for prescription drugs37x’s for prescription drugs

► 51x’s for insurance admin and net cost51x’s for insurance admin and net cost

While GDP increased 12x’s and While GDP increased 12x’s and population grew 41%population grew 41%

Health Care SpendingHealth Care Spending► 2008 health spending (estimated) 2008 health spending (estimated)

$2.39 $2.39 trilliontrillion ($2,390,000,000,000) ($2,390,000,000,000)

$7,868 per person (2008 estimate)$7,868 per person (2008 estimate)► Increased from $2000-$4600 from 1980-2000Increased from $2000-$4600 from 1980-2000

$421 billion increase over 2005$421 billion increase over 2005

► Projected to reach $4.3 trillion by 2017, Projected to reach $4.3 trillion by 2017, nearly 20% of the economynearly 20% of the economy

And the Results?And the Results?1960: U.S. Infant mortality 131960: U.S. Infant mortality 13thth (of 28 developed (of 28 developed

countries)countries) Women's Life expectancy 15thWomen's Life expectancy 15th Men's Life expectancy 20th Men's Life expectancy 20th

2005: U.S. Infant mortality 252005: U.S. Infant mortality 25thth among 28 developed among 28 developed countries (just behind Hungary & Poland)countries (just behind Hungary & Poland)

Women's Life expectancy 7thWomen's Life expectancy 7th Men's Life expectancy 9Men's Life expectancy 9thth

2008: “US falls further behind on infant mortality 2008: “US falls further behind on infant mortality rates. Between 2000 and 2005, the US made only rates. Between 2000 and 2005, the US made only tiny gains, dropping to 29th globally, tied with tiny gains, dropping to 29th globally, tied with Poland and Slovenia.”Poland and Slovenia.”

Health Care SpendingHealth Care Spending

Healthcare’s major role has become Economic Engine

Annual Health Insurance Premiums and Annual Health Insurance Premiums and Household Income, 1996 to 2005Household Income, 1996 to 2005

(Robert Graham Center: Devoe et al)(Robert Graham Center: Devoe et al)

So!So!

What are we to do?What are we to do?

Dr. Margaret ChanDr. Margaret ChanDirector-General, WHODirector-General, WHO

2008 World Health Assembly 2008 World Health Assembly AddressAddress

““When I took office last year, I called for a When I took office last year, I called for a return to primary health care as an return to primary health care as an approach to strengthening health approach to strengthening health systems. My commitment has deepened.”systems. My commitment has deepened.”

“ “ If we want to reach the health-related If we want to reach the health-related Millennium Development Goals, we must Millennium Development Goals, we must return to the values, principles, and return to the values, principles, and approaches of primary health care.”approaches of primary health care.”

Global Health Perspective: WHO 2008 Global Health Perspective: WHO 2008 on WHY Integrating Mental Health into on WHY Integrating Mental Health into

Primary Care Is So ImportantPrimary Care Is So Important

► The burden of mental disorders is great.The burden of mental disorders is great.► Mental and physical health problems are Mental and physical health problems are

interwoven.interwoven.► The treatment gap for mental disorders is The treatment gap for mental disorders is

enormous.enormous.► Primary care for mental health enhances Primary care for mental health enhances

access, human rights, affordability, and access, human rights, affordability, and effectiveness.effectiveness.

► Primary care for mental health generates Primary care for mental health generates good health outcomes.good health outcomes.

IOM 2006IOM 2006

►Overarching Recommendation 2. Overarching Recommendation 2.

The aims, rules, and strategies for The aims, rules, and strategies for redesign set forth in Crossing the redesign set forth in Crossing the Quality Chasm should be applied Quality Chasm should be applied throughout M/SU health care on a day-throughout M/SU health care on a day-to-day operational basis, but tailored to to-day operational basis, but tailored to reflect the characteristics that reflect the characteristics that distinguish care for these problems and distinguish care for these problems and illnesses from general health care. illnesses from general health care.

IOM 2006IOM 2006

►Recommendation 5-1. Recommendation 5-1.

To make collaboration and coordination To make collaboration and coordination of patients’ M/SU health care services of patients’ M/SU health care services the norm, providers of the services the norm, providers of the services should establish clinically effective should establish clinically effective linkages within their own organizations linkages within their own organizations and between providers of mental and between providers of mental health and substance-use treatment. health and substance-use treatment.

IOM 2006IOM 2006► Recommendation 5-2. Recommendation 5-2. To facilitate the delivery of coordinated care by To facilitate the delivery of coordinated care by

primary care, mental health, and substance-use primary care, mental health, and substance-use treatment providers: Primary care and specialty treatment providers: Primary care and specialty M/SU health care providers should transition along a M/SU health care providers should transition along a continuum of evidence-based coordination models continuum of evidence-based coordination models from (1) formal agreements among mental, from (1) formal agreements among mental, substance-use, and primary health care providers; to substance-use, and primary health care providers; to (2) case management of mental, substance-use, and (2) case management of mental, substance-use, and primary health care; to (3) collocation of mental, primary health care; to (3) collocation of mental, substance-use, and primary health care services; substance-use, and primary health care services; and then to (4) delivery of mental, substance-use, and then to (4) delivery of mental, substance-use, and primary health care through clinically integrated and primary health care through clinically integrated practices of primary and M/SU care providers. [read practices of primary and M/SU care providers. [read #4 as, “Make room for mental health and substance #4 as, “Make room for mental health and substance use problems in the Person Centered Medical use problems in the Person Centered Medical Home.”]Home.”]

IOM 2006IOM 2006

► Recommendation 9-2. Federal and state agencies Recommendation 9-2. Federal and state agencies and private foundations should create health and private foundations should create health services research strategies and innovative services research strategies and innovative approaches that address treatment effectiveness approaches that address treatment effectiveness and quality improvement in usual settings of care and quality improvement in usual settings of care delivery. To that end, they should develop new delivery. To that end, they should develop new research and demonstration funding models that research and demonstration funding models that encourage local innovation, that include research encourage local innovation, that include research designs in addition to randomized controlled trials, designs in addition to randomized controlled trials, that are committed to partnerships between that are committed to partnerships between researchers and stakeholders, and that create a researchers and stakeholders, and that create a critical mass of interdisciplinary research critical mass of interdisciplinary research partnerships involving usual settings of care. partnerships involving usual settings of care.

Harris Poll: September 2008Harris Poll: September 2008

• “A strong majority of self-identified registered voters want the next president to make health care reform a top priority and start working on it immediately after taking office.”

• “Adding the patient-centered medical home model to either presidential candidate’s health care plan had a positive effect on the respondents’ support, with about half of U.S. adults indicating they would be more likely to support either plan if the PCMH model were included. Moreover, the survey found that for those respondents who expressed an opinion of support for the patient-centered medical home model, more than 75 percent would increase their support for the next U.S. president’s health care reform plan if it includes a patient-centered medical home.”

Best Practice Panelists at the Best Practice Panelists at the Federal Partners Nov 18-19, 2008 Federal Partners Nov 18-19, 2008

Morehouse ConferenceMorehouse Conference

►La Clinica de la RazaLa Clinica de la Raza►Cherokee Health SystemCherokee Health System►Fayette CompaniesFayette Companies►Intermountain Health CareIntermountain Health Care►White River Junction VA Medical White River Junction VA Medical

CenterCenter►Michigan Mental Health CenterMichigan Mental Health Center►Alaska South Central FoundationAlaska South Central Foundation

Redesigning PracticeRedesigning Practice

Summary and ConclusionSummary and Conclusion

► There is an urgent need for ACTION.There is an urgent need for ACTION.► There is compelling evidence to integrate the There is compelling evidence to integrate the

care of people with emotional and behavioral care of people with emotional and behavioral problems with the rest of clinical care.problems with the rest of clinical care.

► The redesign of primary care is an The redesign of primary care is an unprecedented opportunity to work together.unprecedented opportunity to work together.

► We have a large, skilled workforce to deploy.We have a large, skilled workforce to deploy.► There is a lot of money in play, renewable There is a lot of money in play, renewable

annually.annually.► We know enough about what to do to begin.We know enough about what to do to begin.

A Re-framingA Re-framing

► We should speak of people with “emotional We should speak of people with “emotional and behavioral issues that derive from brain and behavioral issues that derive from brain problems.”problems.”

► We should end the separate histories of We should end the separate histories of mental and physical “diseases” and mental and physical “diseases” and treatments.treatments.

► We are positioned to seize, not the We are positioned to seize, not the opportunity of a lifetime, but an opportunity opportunity of a lifetime, but an opportunity of several centuries finally actionable. of several centuries finally actionable.

► It’s time to make room for mental health in It’s time to make room for mental health in the person centered medical home.the person centered medical home.

A Question to Consider:A Question to Consider:

IS IT NOT TIME FOR A NATIONAL IS IT NOT TIME FOR A NATIONAL PROGRAM OF COMPARATIVE CASE PROGRAM OF COMPARATIVE CASE STUDIES--STUDIES--

TO GUIDE THE WIDESPREAD REDESIGN TO GUIDE THE WIDESPREAD REDESIGN OF CARE TO UNITE PRIMARY CARE, OF CARE TO UNITE PRIMARY CARE, “MENTAL HEALTH,” AND PEOPLE WITH “MENTAL HEALTH,” AND PEOPLE WITH EMOTIONAL AND BEHAVIORAL EMOTIONAL AND BEHAVIORAL PROBLEMS?PROBLEMS?

Why Now Is the Right Why Now Is the Right Time to Work TogetherTime to Work Together

Because we are resource rich, empowered with Because we are resource rich, empowered with new knowledge and technology.new knowledge and technology.

Because we have ideas that are ripe for testing Because we have ideas that are ripe for testing and widespread implementation.and widespread implementation.

Because none of us can make this transformative Because none of us can make this transformative leap alone--we need each other!leap alone--we need each other!

Because we lack evidence that this is a good time Because we lack evidence that this is a good time to wait, keep on doing what we are doing now.to wait, keep on doing what we are doing now.

Because people with emotional and behavioral Because people with emotional and behavioral problems suffer needlessly and die before their problems suffer needlessly and die before their time—because of our inaction.time—because of our inaction.

Because it is necessary, possible, timely, and—Because it is necessary, possible, timely, and—RIGHT!.RIGHT!.

THANK YOU for LISTENING!THANK YOU for LISTENING!

Of course, Of course,

While an organism, and a system, will While an organism, and a system, will change to preserve itself,change to preserve itself,

"It is not necessary to change.  "It is not necessary to change.  Survival is not mandatory.” Survival is not mandatory.” -W. Edwards Deming-W. Edwards Deming