Commentary

by Peter Brown*

Peterbrown.jpgWhen I told Don Berwick that people with a serious behavioral health problem generally die at least 25 years sooner than the average person he was shocked and dismayed. Our conversation occurred at the offices of the Institute for Healthcare Improvement in January of 2007. This was several months after the stunning report of the National Association of State Mental Health Program Directors (NASMHPD) documenting again the loss of years of life for people with a serious behavioral health problem had been published in July of 2006. He immediately saw this as a major public health problem, and one which needed the same sort of attention as any other.

Dr. Berwick, who was recently given a recess appointment by President Obama to be the Administrator of the Center for Medicare Medicaid Services, is that rare combination of a systems thinker and a high class, experienced clinician. He understood the statistic on lost years of life as proof of how our systems have failed both people with a serious behavioral health problem and the rest of us who are deprived of their knowledge, contribution and companionship.

I first met Don Berwick over a decade ago when his Institute for Healthcare Improvement was just eleven years old. He was the first person I had ever heard describe the key problems with healthcare in the US today so concisely, along with ways to start fixing them.

One has only to look at what he has accomplished. He was a major part of the committee that developed the now famous Institute of Medicine report Crossing the Quality Chasm, that laid out the multiple failings in our health care system, saying:

"health care is poorly organized to meet the challenges at hand. The delivery of care often is overly complex and uncoordinated, requiring steps and patient 'handoffs' that slow down care and decrease rather than improve safety. These cumbersome processes waste resources; leave unaccountable voids in coverage; lead to loss of information; and fail to build on the strengths of all health professionals involved to ensure that care is appropriate, timely, and safe."

Don Berwick comes to this from experience as a clinician, as a medical practitioner, as a husband and a father who also receives health care, and as an esteemed teacher. As such, he called for action from "all health care constituencies--health professionals, federal and state policy makers, public and private purchasers of care, regulators, organization managers and governing boards, and consumers."

At our organization, the Institute for Behavioral Healthcare Improvement (IBHI), attention is focused on improving outcomes for people in the behavioral health system. Three of the principles from Crossing the Quality Chasm are especially important:

1. Care is based on continuous healing relationships. Patients should receive care whenever they need it and in many forms, not just face-to-face visits. For people with a serious mental illness, the phrase continuity of care has become a standard rarely met but considered essential.

2. Care is customized according to patient needs and values. The system should be designed to meet the most common types of needs, but should have the capability to respond to individual patient choices and preferences. People with a serious mental illness should be given the same customized care as people receive for other health problems - cancer, kidney disease, diabetes. Too often we hear of prescribing patterns that resemble a mill, of the separation of social support services from medical services.

3. The patient is the source of control. This comes with knowledge of choice. Would anybody force someone with cancer to accept treatment imposed by a radiologist or oncologist? To undergo surgery against his or her will? These are not the standard policies when it comes to people with a mental illness, often denied choice, and robbed of control over basic decisions about treatment, or managing symptoms when there are more than one to choose from.

Three years after the Chasm report, when little had changed, Berwick led the now equally famous 100,000 Lives Campaign to eliminate as many as possible of the unnecessary hospital deaths.

This pioneering effort involved some 3000 hospitals and actually reduced the number of deaths in an 18 month period by over 100,000. Each separate hospital was striving to reduce its particular record of unnecessary deaths. This speaks to a way of measuring outcomes that drive improvement. This project seems clearly to have come from Dr Berwick's convictions about the need to significantly restructure health and health care. His way of solving problems made me realize behavioral healthcare needs to do a lot of catching up.

Measuring outcomes in behavioral health
If only we had such universal measures in behavioral health. At this time we have no way of knowing which organization or provider has a better success rate than another. Without these comparisons different providers and organizations thinks they are providing the best of all possible care. General health care now has developed ways to learn how to improve from each other, but you can only do that by word of mouth in behavioral health. It is only reasonable to expect that behavioral health will be asked soon to develop similar capability. What should we say? How about measuring:


    •Admissions and readmissions to a hospital;

    •Days lost from work or school;

    •Time from door to discharge or placement on maintenance status;

    •Days without permanent housing;

    •And of course - age at death.

Most people would also like to know some measure of efficiency such as cost per person per year.

CMS seems poised to begin asking primary care providers and others in general healthcare to report relative levels of health and costs per capita. Behavioral health should not expect to be left out of that request for long.

Warning signs
The report of the NASMHPD Medical Directors in 2006 is not the first warning we have had that our behavioral health system was failing to fulfill some basic needs. It is well known that cardio-vascular disease, diabetes and pulmonary problems kill people with behavioral health problems far sooner than other people. It certainly ought to be a clarion call to major action. So far the response has been tepid at best. We have no specific set of actions to take or be embarrassed by the failure to take, as IHI proposed in their major campaigns.

We should be asking about our failures that have lead us to this state, and we should be looking across our part of the industry to see whether some one has figured out how to do a better job. It is not unusual to hear people in behavioral health say we do not have a system of care. In fact we do have a system, but it is often poorly organized, with little feedback and minimal establishment of standard paths of care. Moreover, we actually have 50 such systems, at least one in each state. Some of the problems are similar to the problems Dr. Berwick has identified for health care in general. Our system tends to:


    •Think of consumers as objects, not as people, and treat them as if we know best what they need;

    •Put people in danger because of our own treatment choices;

    •Spend money ineffectively because we haven't thought carefully about what is needed or because of the limitations of the reimbursement choices;

    •Give some people too little care (often those with fewer resources) and some people too much. This doesn't mean rationing care or cutting it off, it means making sure people get the right care for their particular issue.

Importantly, one of Dr. Berwick's most important tenets is: we aren't going to do a better job just by trying harder. To make any real difference, we have to change the system of care. Our part of the system seems even more dysfunctional than general health care. Of course general and behavioral healthcare are really just different parts of the healthcare system, so finding similar problems should be no surprise. What's different is general healthcare has started working on addressing these issues with a major quality improvement process and efforts to change the systems.

The changes that are embodied in the Patient Protection and Affordable Healthcare Act, which we call healthcare reform, are going to push our entire field to a host of major changes. Dr. Berwick has demonstrated over and over his compassion for both consumers and providers. He is the one who is best known for telling healthcare professionals "If the results are bad don't blame the people, blame the system." We need this sort of insight, clear thinking and compassion in the coming restructuring of health care, both general and behavioral.

These changes in the entire field of medicine will take a lot of imagination and compassion to implement effectively and expeditiously. If we lose this opportunity to change healthcare, and improved health slips through our grasp, it will be years, possibly decades, before we can find it again.

If we learn from the quality movement IHI and others have developed in general healthcare, we can begin to achieve the same types of improvement in behavioral health. I expect CMS to begin demanding these things from all of healthcare. We must use careful measurement and improvement methods to assure our programs curb illness and extend both life and the quality of life. We owe it to consumers, and to the nation as a whole and we should be embarrassed if we do not deliver.

*Peter Brown is the Executive Director of the Institute for Behavioral Healthcare Improvement, a 501C3 organization dedicated to improving the quality and outcome of care for people behavioral health problems. He was previously Deputy Commissioner of the New York State Office of Mental Health from 1995 to 2004.

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