The Economics of Recovery: System Reform

New York State Governor Andrew M. Cuomo’s Medicaid Redesign Team gathered an impressive list of suggestions to stem the growth of New York’s 50+ billion dollar Medicaid program. I was particularly impressed with their adoption of the 80/20 concept developed by business marketers in the 70’s. Market research for a variety of goods and services found that about eighty percent of the sales were accounted for by only twenty percent of the consumers! Studies applying the 80/20 rule to the consumption of health care services found similar results. This, I believe, led to the creation of “Health Homes” (365-1), probably the most effective system reform tool in the bunch.

However, we feel two other promising paradigms were overlooked: 1) Reducing consumer demand and 2) Applying existing technology. To explore these options, we asked some twenty-four recipients, “If they had a choice, how often would they want to see each of their health care providers?” We found our consumers wanted to reduce the number of visits to their psychiatrists by fifty-eight percent; from an average of 9.5 visits/year to 3.9 visits/year!

Similarly, if given a choice, they also wanted to reduce the number of visits to their therapists by fifty-eight percent; from an average of 13.6 visits/year to 5.6 visits/year!

If consumers had the power to decide how often they see their doctors and therapists, this alone could reduce Medicaid costs by billions.

The question is, does the patient have the ability to make their own mental health decisions regarding how often they want to see their caregivers?

We then gave our folks eight written health care concepts which utilize various technologies to deliver services and asked them to rate each one on how likely they were to use them. The results are below.

24/7 Tele-Hotline Doctor – “Reach a medical Doctor, Internist, Psychiatrist, etc. from your mobile or home telephone, any time of the day or night, to answer your questions” (77% rated this “very/somewhat likely” to use).

Smart phones provide new opportunities for the next generation of psychological health content, particularly among teens and young adults. They provide “always-on” support for the highly mobile, rural and underserved populations. Users receive two-way contact with support systems during a crisis or to manage unexpected acute symptoms. Frequent issues include alcohol and substance abuse triggers, coping with suicidal thoughts, and anger management.

A recent study of group telephone counseling of people at risk of heart disease found the tele-sessions were effective in helping people adhere to their exercise, diet and smoking cessation programs (R. Nolan, 2011). Custom Facebook groups have also proven effective.

Create Your Own Health Plan (VOUCHER) – “With this option the Government would give you a lump sum of money (e.g. $3,000) for you to pay all your health needs for a year. You would decide who to go to and how often, and you would get to keep whatever monies are left over” (73% rated this “very/somewhat likely” to use).

Republicans in the House recently voted to transform Medicare from a program in which the Government pays medical bills directly to a Voucher system that would enable people to purchase private health insurance. A variation of the Voucher Plan is “concierge medicine” where doctors limit their practice to patients who pay a fee of about $1,500 a year, for unlimited access, time and attention. It is catching on out in the west.

24/7 Tele Hotline Therapist – “Reach a Psychotherapist from your cell or home phone, anytime, day or night, to help you with managing your feelings” (73% rated this “very/somewhat likely” to use).

International Tele-Health call centers would be available to help people cope with sleep disorders, anxiety, anger, depression and suicidal thoughts, drug and alcohol abuse, tobacco, physical injury, sexual issues, spouse and children, work adjustment, etc.

A British study found Cognitive Behavioral Therapy (CBT) could be effective in treating depression when administered via instant messaging (Kessler, 2009). Twitter could also be effective.

Video Therapy – “Talk and see your regular Doctor or Therapist through the computer at your regularly scheduled day and time – instead of having to travel to the office” (73% rated this “very/somewhat likely” to use).

We first heard about this technique in the fall of 2009, Dr. Timothy Sullivan, M.D. formerly of Saint Vincent’s Hospital, was able to continue his weekly psychotherapy sessions with patients who moved away.

One-Stop Health Care – “Instead of having to travel all over town to see your different health care providers, you could see them all in one place, on the same day” (64% rated this “very/somewhat likely” to use).

Convenience is the key attraction with this health-care model. The logistical challenge, of course, is arranging all the appointments on the same day. A prime example to check out is, a pioneering HMO here in Westchester County, NY.

Medication Free Health Plan – “This plan would only treat your illness with natural products; e.g. vitamins and herbs, no chemicals or prescription drugs. It would also incorporate yoga, acupuncture, meditation, exercise, social relationships, etc.” (64% rated this “very/somewhat likely” to use).

While about two-thirds of our folks liked this plan, no one questioned the treatment plans’ efficacy. This group also felt “very satisfied” about “their ability to make their feelings known to the Doctor,” “being an active partner in their treatment plan,” and “their ability to make their own medical treatment decisions.”

WATSON –“IBM recently created a powerful talking computer which could provide you with information on a variety of topics; Government benefits, housing, education, work, medical, legal, etc. with no need to type your questions; just ask” (33% rated this “very/somewhat likely” to use).

Watson is just one component of IBM’s Smarter Healthcare initiative designed to master a complex system, including vast networks of doctors, patients, hospitals, clinics, pharmacies, insurers, medical equipment, and the millions of pieces of data, images, prescriptions, documents, and other information that get exchanged every day (, 2010).

Virtual PTSD Game/Avatar – “This game helps people cope with their post-traumatic stress and phobias by placing them in a stressful environment, but one in which they can control. The Army developed it for returning warriors” (18% rated this “very/somewhat likely” to use).

A recent Rand Report found about one-fifth of all service members returning from Iraq and Afghanistan screen positive for mental health problems, and that multiple barriers prevent about half from seeking the information and care they require. These barriers include “perceived stigma, physical access barriers, and limited resources.”

The T2 Virtual PTSD Experience is a self-guided exploration which immerses the visitor in a simulated combat-related traumatic event to demonstrate how PTSD may be acquired, its triggers, the role of avoidance, and the “use of time outs” through a series of interactive activities controlled by the visitor. It is anonymous, available anytime and free of charge.

Preliminary research has shown it is a significant adjunct to web-based resources and face-to-face care. Future applications could include suicide prevention, how to avoid substance abuse and sexually transmitted diseases, pregnancy, etc. among teens and pre-teens.

Remote Job Skills Training

While distance learning has been around for many years, we are just beginning to explore its full potential for vocational training at group and private homes with special needs populations (e.g. Autism Spectrum Disorders/Asperger’s Syndrome, mild Mental Retardation, and the physically challenged).

The Center for Career Freedom began handing out webcams to those students who lived too far away to come to our Microsoft Office training classes every day and to student in group homes who had difficulty accessing the proper transportation. The webcams enabled folks to participate in live interactive classes from the comfort of their own home, regardless of the weather. Facial expressions are clear, through the audio can have a slight delay and there are a few “bugs” that need to be worked out. Files are easily transmitted including templates, completed work, quizzes, teacher feedback, etc.

Cameras run from $20 – $80. provides free 1:1 video services. Other applications we are exploring include: staff training, family video visits, building your on-line community, “Town Hall” meetings, health screening, and dispute resolution.

We may agree challenging times requires innovative thinking (creative problem solving, new tools, experimentation, pilot studies, etc.) but I believe the most effective and efficient solution(s) will be found by providers who have the skills to listen and learn from their clients and the courage (and funding) to turn “solutions” into action.

Publisher’s note: This is Don’s final column for Mental Health News. He is busy launching the Center for Career Freedom’s Microsoft Office Skills Employment Program for persons with mental and physical disabilities. We wish him all success.

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