ABHW’s Vision for a Reformed Health Care System

The Association for Behavioral Health and Wellness (ABHW), formerly the American Managed Behavioral Healthcare Association (AMBHA), is comprised of the nation’s leading behavioral health and wellness companies. Our member companies provide an array of services related to mental health, substance use, employee assistance, disease management, and other health and wellness programs to more than 147 million people in the public and private sectors. 

In recent years, there has been an increasing focus on overall health and well-being of members of managed behavioral health care, including a clear recognition that mental health and substance use services must be components of any plan to improve the overall quality of health care outcomes. This understanding has increased the emphasis on coordination of care, evidence-based practice, quality measurement and improvement, and the development and delivery of wellness programs to foster healthy behavior. 

ABHW and its member companies use their behavioral health expertise to improve health care outcomes for individuals and families across the health care continuum. Our vision, stated below, is to advance a health care system that embodies the six aims of the Institute of Medicine’s Improving the Quality of  Health Care for Mental Health and Substance Use Conditions.

• Recognizes the extensive impact behaviors have on a person’s health, well-being, and functioning;
• Acts to promote behavior that fosters wellness and healthy lifestyles;
• Advances mental health and substance use treatment, acknowledging its interrelationship across systems of care and with a person’s total health;
• Promotes active consumer participation; and
• Improves functional outcomes for individuals, organizations, and industries.

Significance of Mental Health and Substance Abuse Services

ABHW envisions a health care system that facilitates recovery, promotes wellness, and builds a productive, self-actualized workforce through a comprehensive approach to health that combines both the physical and the psychological. Education, activation, and advocacy are instrumental to making this vision a reality.

U.S. Surgeon General Satcher said, “There is no health without mental health.”  To be truly effective, any viable U.S. health care reform efforts must take into account the enormous costs—both financial and social—of behavioral health and must implement strategies to make behavioral health an integral and vital component of overall health.

Evidence demonstrates that mental health and substance use disorders carry a significant societal impact, not only for individuals but also for families, communities, employers, and our nation as a whole. Mental illness and substance use disorders account for a large proportion of traffic accidents, domestic violence cases, crime, and difficulties with employment.  

In addition, the incidence of behavioral health comorbidities among patients with chronic medical illness ranges from 39% to 44%. Despite the common belief that behavioral health cost consumes only 3% to 5% of the medical dollar, with the prevalence of comorbidities, actual behavioral health spending is close to 36% of the medical dollar. Although behavioral comorbidities raise the cost of medical care by as much as 50% to 150%, early identification and intervention and effective care can both reduce medical cost and improve workplace productivity.

Our experience has shown that legislators are often unaware of the pervasiveness of behavioral health comorbidities in the medical environment. ABHW strives to educate and inform not only legislators, but also medical professionals, media, and the public; advocate policies that further our vision; collaborate with stakeholders to create shared goals and strategies; promote quality health care delivery; and cultivate a culture of knowledge sharing. Toward this end, ABHW strongly advocates that the recent passage of federal parity legislation covering mental heath and addictions services under private insurance plans must be preserved. It is imperative that health reform efforts build upon the hard-won accomplishment of insurance parity for behavioral health services. 

A New Health Care System and Benefits Package

ABHW’s vision for a reformed health care system would be to allow maximum collaboration and care management that bridges the current gaps between behavioral health care and medical care and eliminates fragmentation and decreases the unsubstantiated variability in care. Essential to success is a model that spans public and private systems and aligns diverse stakeholders to define objectives, set priorities, increase efficiency and reduce duplication, thereby cutting out unnecessary costs and providing more and better care for a greater number of people. This alignment will generate a consensus on ethical approaches, values, and standards providing accountability to the National Institute of Mental Health’s four key objectives:

• Promote discovery in the brain and behavioral sciences to fuel research on the causes of mental disorders;
• Chart mental illness trajectories to determine when, where, and how to intervene;
• Develop new and better interventions that incorporate the diverse needs and circumstances of people with mental illnesses; and
• Strengthen the public health impact of NIMH-supported research.

ABHW contends that a new health care system should rely on the IOM’s Improving the Quality of Health Care for Mental Health and Substance Use Conditions and the final report by the President’s New Freedom Commission on Mental Health as touchstones to develop policies and best practices that will drive the nation toward improved health and wellness, with specific objectives and milestones to measure progress. Requiring a certain level of consistency is not intended to interfere with the need for free market nor inhibit the style of business execution of the individual agencies.  Balancing the value of standardization and free enterprise may be difficult, but open communication among agencies, institutions, and individual providers as well as federal policy addressing the challenge will go a long way toward building a seamless public-private partnership. 

Whereas the current health system encourages providers to take on as many clients as possible and retain them as long as possible irrespective of outcomes, we envision a system that will effectively steer consumers to the appropriate levels of care with clear diagnostic criteria and efficient treatment with clear goals targeting symptoms and leading to symptom improvement and completion of treatment. This new system would equip non-behavioral health practitioners with the knowledge and skills to better identify and treat (when appropriate) behavioral health conditions and to advise patients on the range of available services and modalities of care. Additionally, the new system we envision will ensure that all individuals have access to affordable health insurance, which allows them to make more rational decisions about entering the behavioral health care system. When consumers have appropriate access, they can address conditions at a lower level of acuity and achieve better outcomes at a lower level of cost.

ABHW envisions a benefits package that covers the full spectrum of services from outpatient through intermediate to inpatient care including not only hospital care and physician visits, but also home health, medication, community services, and supervised housing for individuals unable to live independently.  Managed care services are necessary components to help contain costs and ensure quality in this newly designed health care system.  “Evidence on the effects of managed care suggests that they have been instrumental in reducing inpatient admissions, inpatient length-of-stay, and total spending on inpatient care, with a concomitant increase in outpatient visit rates across the health sector.”  Underpinning these services is a strong foundation in evidence-based medicine spanning preventive care, health maintenance, and treatment. To evaluate the effectiveness of specific interventions and the system as a whole, we propose a move from measurement on the process and procedural level to assessment of actual clinical outcomes and improvements that will ensure transparency.

Other Considerations

Any system can be only as successful as the infrastructure that supports it, and ABHW recognizes that the U.S. health care system faces significant structural challenges. One inevitable development, and perhaps an essential element in driving coordination of care, is health information technology (HIT) and the widespread use of electronic health records (EHRs). Not only do EHRs enable providers to have access to chronological histories of consumer care and interventions, but they also allow large-scale data analysis that can yield valuable insight into the efficacy of treatment plans. Among the challenges to strengthening the national HIT infrastructure are resistance to change, financial limitations, and privacy concerns. However, education, reallocation of funding through increased efficiency, and clear usage guidelines hold the solutions to each of these problems.

Another essential element of health reform is attention to workforce issues. The current behavioral health workforce is inadequate in size and provider training needs improvement.  It is important to pay attention to both recruitment and retention.  Providers need to be incentivized to enter and remain in the behavioral health field.  In addition there is a basic understanding that all health professionals need as it relates to the screening, intervention, treatment and referral for mental health and substance use disorders.

Conclusion

The Association for Behavioral Health and Wellness is pleased to provide SAMHSA with this document detailing our initial thoughts on what a reformed health care system should look like.  We appreciate the opportunity to be partners with SAMHSA and as the discussions on health care reform continue we hope that we can continue to work together and be a resource.