Twelve Challenges To The Future Of Behavioral Health
Thomas Miller
Professional Board Liaison for Association for Ambulatory Behavioral Healthcare
by Thomas Miller
Twelve points of inquiry lie at the heart of behavioral health policy. Despite their appearance, these critical issues are profoundly interdependent. Consider, for instance, a scenario in which a number of individuals who suffer from serious emotional distress choose to avoid treatment and live with their condition. Should we concentrate on their right to refuse care, bemoan the overall negative impact on public health, or applaud these actions as one way to reduce treatment costs? On another note, consider how the following dynamics influence the national discourse on the “opioid crisis.”
1. Presently, behavioral treatment is defined as an essential healthcare benefit. If this changes, insurers can raise premiums for those with pre-existent conditions, increase out-of-pocket expenses, limit treatment options, and decrease access to care.
2. Scientific evidence competes with moral beliefs to shape the discussion about personal responsibility, behavioral causation, victimization, and treatment.
3. “Mental health” and “substance abuse” services have matured within separate silos, limiting the development of integrated treatment for people who experience both problems concurrently.
4. Despite early screening efforts, people often wait to seek help until they face a serious emotional crisis, resulting in the need for more intensive and expensive interventions to avert negative outcomes such as self-harm or job loss.
5. The line between “medical necessity for treatment” and “basic emotional distress” is often controversial since it generally defines payment eligibility.
6. The accurate measurement of untreated versus non-existent behavioral conditions is complicated by individual choice, cost, stigma, and access to care.
7. Technological innovations such as smartphones, cameras, and video games are producing powerful shifts in the emotional life and behavior of people requiring enhanced assessment and treatment initiatives.
8. Our understanding of individual, community, and environmental problems is challenged by the regulated privacy of personal health information and the need for comprehensive public health information.
9. The parameters for “involuntary” treatment have been designed with great care, but individuals at risk for harm to self or others continue to avoid treatment by denying feelings, disguising intentions, or temporarily controlling behaviors.
10. The design of electronic medical records tends to be more focused on payment and regulatory requirements than continuous patient care improvement.
11. Fear of litigation produces a business environment where strategies to minimize risk can stifle treatment innovation, increase administrative costs, and complicate overall policy formulation.
12. “Fee for service” competes with “case rate” payment methodologies as insurers, managed care organizations, and treatment professionals confront the conflicting mandates of “profit maximization” and “treatment effectiveness.”
I believe the content of each of these topics must be part of the decision- making process in the future design of behavioral healthcare.
One of the biggest issues is also a lack of standardizations around a defined lexicon in this vertical of healthcare. In regards to point 12, how can "treatment effectiveness" be fundamentally misaligned with profit maximization if there isn't a clear definition around what is effective or successful? Measuring mental and behavioral health outcomes is exponentially more difficult vis-a-vis other verticals of healthcare because clinical records are largely unstructured data sets (as opposed to other types of disease where monitoring effectiveness is more quantitative). The goal should be to standardize definitions set up by a joint task force made up of clinicians and payor executives- then incentivize treatment operators to invest in the quality of care within their programs. Measurement definitions should also be associated with every modality. This would result in the alignment of incentives amongst the payors, treatment operators, clinicians, and patients. Insurance companies start to reallocate capital reimbursements to providers that cost them less money in the aggregate, operators are monetarily incentivized to achieve better outcomes as a means of generating top-line revenue growth, and clinicians and patients start benefiting from the overall rise in quality treatment across the continuum of care as poorer quality providers find it harder and harder to compete.
Former Commissioner/Director: VA, WA, TN, NH. Subject Matter Expert: Government Health and Human Services Policy/Strategy: BH, SUD, DD, CW, LTC, IT/HIE; Inclusive Medicaid Policy/Planning/Implementation Development
6 年Interesting and important. Many of the 12 points payment, regulations, and EHR impact on quality care are health care meta-systemic issues and there well known evidence based practices addressing co-occuring disorders such as Ken Minkoff's work in this field.