Sheppard Pratt Health System
Towson, Maryland - December 16, 2009
Thank you, Steve, for that introduction. Steve and I go way back. We served together on a Clinton Administration commission on improving quality in our health care system. And one of the best parts of that experience was getting to meet Steve and learn about the great work he’s doing here at Sheppard Pratt. Steve has a passion for trying to do health care better. And that’s reflected in Sheppard Pratt, which has become a model for how to provide effective mental health services, not just in this area, but in the entire country.
I also have to mention Steve’s greatest accomplishment in my opinion, which was raising an incredible son named Josh, who’s now our Principal Deputy Commissioner at the Food and Drug Association. So I have to thank Steve for that.
I also want to add my own praise for Secretary Colmers. I’m not going to try to top what Steve just said. But I can say that this fall, I’ve gotten to work closely with state health secretaries around the country on fighting the H1N1 flu. And I can tell you that Secretary Colmers is doing a great job. A couple months ago, I was up in Maryland at a school-based flu clinic. This was right at the beginning of flu season, and I was very impressed by how quickly they had this clinic set up to get kids vaccinated. So I’m a fan of Secretary Colmers’ work too.
Finally, I want to acknowledge Pam Hyde, our new Administrator for the Substance Abuse and Mental Health Services Administration, who’s here with me today. We stole Pam from New Mexico where she led their human services department. Some of you may know that she has more than 30 years of experience dealing with behavioral health issues in state government, city government, and as the CEO of non-profit behavioral health managed care firm. She was just sworn in last week. I don’t know if she’s had time to unpack yet. But we’ve already had the chance to get together and talk about our plans for the next few months, and I know she’s going to be a great leader for SAMHSA.
One of the things Pam and I have talked about is the huge opportunity we have in the next couple of years to make some big improvements in the lives of Americans with mental illnesses and substance abuse disorders. There are a lot of changes happening right now that could have a big impact on behavioral health: parity, health insurance reform, the growing popularity of integrated care models, an increased focus on prevention, huge gains in our understanding of the science behind mental illness and substance abuse.
These changes are creating a lot of potential for progress, but we also know that nothing is guaranteed. The integrated care models that spread could have a strong mental health component. Or they could not. We might find effective ways to apply some of the research we’re doing. Or we might not. In order to get the most out of the next few years, all of us in government, the private sector, and the non-profit world are going to have to work hard to steer these changes in a direction that benefits our friends and neighbors with mental illnesses and substance abuse disorders.
So that’s what I want to talk about today. But I think it’s important to start by recognizing how far we have to go. Mental illness and substance abuse are far more common than most Americans realize. About one in five Americans will have a mental illness this year. Almost half of Americans will have a mental illness in their lifetime. And we know that many of these people do not get the care they need. More than ten million adults said they didn’t get the mental health care they needed last year. About twenty million said they didn’t get the substance abuse care they needed.
If ten or twenty million Americans were walking around with open wounds, we’d call it a national crisis. But because mental illnesses and addictions can be harder to see, we don’t feel the same urgency. And yet, the costs of mental illness are right there in front of us. Thirty-two thousand Americans commit suicide each year. People with mental illness make up half of the 700,000 homeless people in America. People with substance abuse disorders account make up four out of five prisoners. The National Academies estimate that mental illness in Americans under 25 alone costs our country almost $250 billion a year.
Given the high price we pay for these gaps in care, the Mental Health and Addiction Equity Act, which Congress passed last year and which will soon go into effect, is a huge step forward. Congress should be commended for passing the bill, especially the late Senator Paul Wellstone and Senator Domenici who fought for it for years. And I also want to commend all of you in the advocacy community for helping to educate members of Congress about this important issue.
Thanks to parity, millions of Americans with mental illness and substance abuse disorders will get the care they need. It’s going to help people afford their medicines. It’s going to make them less likely to put off important care. And it’s also an important symbolic step. For years, we thought about mental illnesses and addictions in terms of its costs for the rest of us who weren’t sick. Then we slowly began to acknowledge, “okay, maybe we can help some of these people.” And it’s only been recently that we’ve contemplated the possibility of full recovery. Parity establishes the principle that as a society, we have just as much of an obligation and interest in treating diseases of the brain as we do diseases that affect the rest of the body.
That said, we need to understand what we mean when we say parity. What we’re really talking about is “parity in reimbursement by private health insurance plans that cover mental health and substance abuse services.” That’s significant, but it’s just a starting point. A broader definition of parity would encompass investments in prevention, investments in health care delivery reform, investments in support services like housing that can affect behavioral health outcomes, and investments in treatment and service system research. And it’s this fuller version of parity that we should be striving for.
One idea we’ve talked a lot about is integrated care. The idea here is that providers deliver higher quality care when they work as a team. So say you have diabetes. Instead of being told, “You need to exercise more and eat better. Come back and see me in six months,” you have a team of nurses and dieticians working with you to figure out a diet and exercise plan that you can stick to. And the same approach can work for mental illnesses and addictions. Mental health and addiction professionals can serve as what are called “recovery navigators,” helping to connect patients with health screening, as well as counseling, medication management, housing, and job training.
We know that these integrated care models can be especially effective when they combine behavioral and physical health conditions. That’s because mental illnesses and substance use disorders usually go hand in hand with other physical conditions. We know that the sicker you are, the more likely you are to be depressed: forty percent of older patients with advanced heart failure have major depression. And we also know that when physical and mental health problems come together, they usually make each other worse. For example, the cost of treating a patient a medical problem and comorbid psychiatric condition is twice as high as the cost for a patient with the medical condition alone.
We already have several successful examples of how to provide this kind of integrated care. Health care systems like Cherokee Health, Intermountain Health, and the Veterans Administration have all successfully included mental health into their primary care systems. Now the challenge is to spread these models, especially to smaller practices that may not have the same experience dealing with mental health and substance abuse problems.
And we also need to make integration work the other way. We know that barely half of public mental health centers have the capacity to provide medical treatment for physical health problems either onsite or through referral. We need to do better, and SAMHSA is currently administering a grant program designed to figure out how we can incorporate primary care services into these community behavioral health centers.
Another idea that we need to borrow from our work to improve our physical health care system is investing in prevention. We know from the latest research that half of all mental illnesses begin by age 14. Three fourths begin by age 24. We also have decades of research showing that the most cost-effective mental health interventions are the ones that prevent or delay the onset of mental illnesses. Part of why these early interventions are so effective is that they can also prevent associated problems like drug use. We know for example that kids between the ages of 12 and 17 who were depressed in the past year were twice as likely to take their first drink or use drugs for the first time as those who did not experience depression.
So there’s a lot to gain by preventing mental illness. And while we still have more to learn about which of these interventions work best, we’re aggressively looking for answers. For example, the National Institute of Mental Health is currently conducting a major early intervention trial for people who have just experienced their first episodes of schizophrenia. What makes this research unique is that we’ve already assembled a working group from three of our agencies including SAMHSA that is thinking about how we could pay for this intervention if the study is successful. Given the benefits of prevention, we want to make sure we’re moving as fast as possible to implement the best ideas we have.
A third idea we need to incorporate into our mental health and substance abuse response are partnerships that go outside the public health community. Just as we understand that our physical health is affected by food we eat and the air we breathe and the physical environment we live in, we need to realize that prescription drugs and counseling are not the only factors that affect our mental well-being.
For example, we know that two of the most effective tools we have to help people recover from mental illnesses or addictions are a home and a job. That’s why my department is working with the Department of Housing and Urban Development on a demonstration project that will combine housing vouchers with behavioral health and other support services to see if this combination can help reduce homelessness for people with severe mental illness or substance abuse disorders. We’ve already seen one study in Chicago where providing housing and case management reduced hospital stays and emergency room visits by 25 percent, and we want to try to build on that success.
We’ve also formed partnerships to help us reach some of the Americans with mental illnesses who may not be getting the services they need. So we’re also working with the Department of Education and the Department of Agriculture to promote behavioral health in schools. We’re working with the Veterans Administration to reach veterans. We’re working with the Department of Labor and other agencies to reach out to families in the cities that have been hardest hit by the economic downturn. And if we’re going to treat mental illness and substance abuse effectively, we’re going to need more of these partnerships, public and private.
Of course, the change that you’re probably most curious about is health insurance reform. And I’m sorry to say, I didn’t come here today to announce a secret deal. As you’re all aware, the House has passed a bill and the Senate is still trying to work out the details on its own bill. We in the Obama administration are continuing to support them any way we can.
But while we can’t know exactly what the final reform bill will look like, we do know that any reform bill that meets the President’s basic criteria will have huge benefits for Americans with mental illnesses and substance use disorders. Any reform bill will expand access to insurance, which will especially benefit people with mental illnesses who we know are twice as likely to be uninsured. It will prevent insurance companies from calling your substance addiction a preexisting condition and denying you coverage. Through pilot programs and new incentives, reform will encourage the kind of integrated care models and prevention strategies I talked about earlier.
At the same time, we know that even the strongest reform bill will not provide all the services that Americans with the most serious and disabling mental and substance use disorders need. That’s why it’s so important that we continue to work to prevent these conditions from occurring and deliver the services that help Americans with these disorders fully recover and become contributing members of society.
To do that, we’ll need your help. As much progress as we’ve made, there is still a long way to go. We need you to be advocates not just for more resources for mental health and substance abuse prevention and treatment, but for smarter use of those resources. We have a better understanding than ever before about the kind of programs that are most effective, and we need to apply that knowledge to get the best results.
Through it all, we need to remember that health is one of the best investments we can make. When people are mentally and physically well, they miss fewer days of work and get more done. They pay more taxes. They can take care of their grandkids. They can play softball. They can volunteer at the town library. They can walk to the grocery store. They can get a good night of sleep.
I’m sure we’ll be having many conversations in the months to come about how to build a healthier country, and I’m sure you’ll be talking to Pam as well. For now, we’ll be happy to take a few of your questions.