“If we really think about how to change healthcare to make it more accommodating for integration, we must have comprehensive payment reform that pays for the whole, and not the part. We must recognize that administrative structures in health policy entities often perpetuate fragmentation inadvertently. And we must have a way to collect data that can inform not only the clinical case for why integration is good, but the business case for why integration is inevitable.”
Dr. Benjamin Miller
Healthcare policy plays a crucial role in integrated care. Our current healthcare system contains barriers that prevent successful implementation of behavioral health and primary care integration. We will not be able to effectively adopt whole-health approaches to healthcare until critical changes are made in existing health policy. Thankfully, we can be grateful for those who are out there, tirelessly advocating for changes daily.
Dr. Benjamin Miller has graciously agreed to offer his insights on this important topic for the Integrated Care Thought Leader Series. He has made significant contributions to the healthcare industry and health policy, and continues to collaborate with a number of organizations focused on driving the necessary change for creating a more effective healthcare system. Dr. Miller has been the source of considerable inspiration to many (including me). It seems very appropriate, somehow, that I first met him through Twitter. His many tweets on healthcare, policy, and integration, with excellent links to current resources, provide me and many others with an education like no other. I have learned the value of Live Tweeting and Tweet Chats through his example (see Figure 1 below). Thank you, @miller7!
Dr. Miller is an Assistant Professor in the Department of Family Medicine at the University of Colorado Denver School of Medicine where he is the Director of the Office of Integrated Healthcare Research and Policy. Dr. Miller is a principal investigator on several federal grants, foundation grants, and state contracts related to comprehensive primary care and mental health, behavioral health, and substance use integration. He leads the Agency for Healthcare Research and Quality’s Academy for Integrating Behavioral and Primary Care project as well as the highly touted Sustaining Healthcare Across Integrated Primary Care Efforts (SHAPE) project in Colorado and Oregon.
He received his doctorate degree in clinical psychology from Spalding University in Louisville, Kentucky. He completed his predoctoral internship at the University of Colorado Health Sciences Center, where he trained in primary care psychology. In addition, Miller worked as a postdoctoral fellow in primary care psychology at the University of Massachusetts Medical School in the Department of Family Medicine and Community Health.
He is the co-creator of the National Research Network’s Collaborative Care Research Network, and has written and published on enhancing the evidentiary support for integrated care models, increasing the training and education of mental health providers in primary care, and the need to address specific healthcare policy and payment barriers for successful integration. He is the section editor for Health and Policy for Families, Systems and Health and reviews for several academic journals. Dr. Miller is a technical expert panelist on the Agency for Healthcare Research and Quality Innovations Exchange and on the International Advisory Board of the British Journal of General Practice. Miller is the past President of the Collaborative Family Healthcare Association, a national not-for-profit organization pushing for patient-centered integrated healthcare.
Having long been a firm believer in the need to provide healthcare in a unified manner, Dr. Miller has determined that three barriers prevent integrated care from becoming more widespread: Financing, policy, and data.
Dr. Miller: If you ask people why integration is or is not making a larger stand in healthcare, it usually comes out that they aren’t able to sustain their clinical innovation. So practices try to figure out ways that they can sustain themselves through all kinds of workarounds. Here in Colorado about three years ago we did a survey of integrated practices and found that 77% of those we surveyed were solely funding their integrated efforts through grants. I don’t think that’s uncommon. Actually, I think it’s very common across the country. A lot of practices that are doing this got funding from foundations, federal government, etc., to make it work. They’re only able to keep their doors open for the program while they’ve got those dollars. I wanted to figure out, why is that such a big deal? Why can’t we just pay for health? We proposed a project to test out a global payer model for primary care that includes the cost of mental health, just to see if we were to pay primary care a lump-sum of money that includes the cost of that primary care provider, could they sustain themselves? That’s where the Sustaining Healthcare Across Integrated Primary Care Efforts or SHAPE came from. We wanted to see if paying for primary care differently with mental health, behavioral health, substance abuse providers, working in that integrated context could be sustained. We’re about a year into that and the answer is going to be unanimously, yes.
Large Scale Policy Issues and History
Dr. Miller: If you look at how healthcare is set up, it’s set up to continue to perpetuate fragmentation. It’s set up so that administratively, it’s easier to manage pieces rather than a whole. Our states, communities, and government have done something, in an attempt to manage multiple systems, which has really hurt our attempts to integrate. I’ll give you a very high-level example of that: If you just look at most states, they usually have a different department or division for mental health. We decided to take all the dollars that were going into institutions for folks that had mental health issues and put it back into the community in established community mental health centers. The dollars didn’t really follow the patients in that experiment. Community mental health centers actually didn’t get a whole lot of money to do the job that they were intended to do. And so you have entire systems at state levels that manage mental health. When you want to try and integrate, whether it be in primary care or in the community mental health center with primary care, there are multiple administrative structures that you have to figure out how to align. And often, from a policy perspective, it doesn’t make sense fiscally as to how to align these and what to do with the administrative entities. There are a lot of policy issues. Mainly, how we’ve set up our systems to deliver care at the policy level.
Data, Research, and Infrastructure
Dr. Miller: The other reason I think integration hasn’t been taken to scale nationally as much as we would like, is that practices are relatively immature in their ability to collect data, especially as it relates to collecting that informs the outcome around the whole person and not just a physical health outcome or mental health outcome. If you go into a primary care practice and want to determine how effective a behavioral health provider is, often the electronic medical record and how they are tracking the data are in forms that don’t allow you to extract those data. They’re in free-text notes, or they’re in something that just makes it difficult to get at the data to show what they did and how effective it was. In the same vein, if you look at community mental health centers, it’s even worse. With vast amounts of EHRs, if they even have an EHR, are built around this old-fashioned, almost antiquated, “I need to tell the whole story for the patient” model. That’s good on the clinical level. However, if you’re looking at making a case for something, you need to be able to extract data from those electronic medical records and then tell a story with your data. Many of the community mental health centers simply are not there. They have an opportunity here to advance themselves by collecting better data at the practice level.
Though many in the healthcare industry see policy as something beyond their responsibility and concern, the reality is that it has an impact on each of us. Unless we collectively express our concerns, voice our professional opinions, demand the necessary changes, legislators will continue to make uninformed decisions that have significant impact on healthcare delivery.
While there remains a long way to go before the needed changes outlined by Dr. Miller are in place, the industry as a whole is making significant strides in the right direction. Policies are slowly beginning to change.
Perhaps the perfect storm is approaching for healthcare.
Figure 1: Ben Miller live tweeting at the 2010 CFHA Conference in Louisville, Ky.