A revolution in the payment and delivery of behavioral health services is poised to transform the healthcare industry and all of its participants. Key stakeholders, including service recipients and their families, medical professionals, social service and community-based organizations, governmental regulators, public and commercial payers, advocates and educators, to name a few, anticipate seismic shifts that will rattle the foundations of our service systems. Lasting repercussions, expected and unexpected, desired and undesirable, are inevitable.
Many with significant behavioral health needs rely on a publicly-funded service infrastructure that becomes more fragile in the face of increasing demand and diminishing resources. There are perhaps no resources more critical to the success of service organizations than their human resources – the deeply committed professionals and paraprofessionals who endeavor to improve the lives of those entrusted to their care despite significant challenges and modest remuneration. How might these resources be cultivated and deployed to properly address the emerging needs and contingencies of a transformed healthcare system? What is the charge of the new behavioral health workforce and what forms will it take? I proceed from an admittedly radical premise that this workforce should not be a behavioral health workforce at all. It should simply be a “wellness” workforce whose composition reflects the primacy of social and physical determinants of health in the recovery process. It should also be one that acknowledges the limitations of our conventional approach to the management of chronic illness. This approach erroneously applies an acute-care model of disease management more appropriate to the eradication of pathogens than the amelioration of conditions in which various factors, including genetics, socioeconomic status, lifestyle habits, historical influences (e.g., exposure to trauma, etc.) and the availability of social and emotional support networks are implicated. We must reconcile the medical and sociocultural history of this approach and the economic context in which it thrives with the current realities of chronic illness if we hope to promote meaningful and sustainable recovery for individuals with behavioral health conditions.
Our nation allocates a disproportionate share of resources to conventional healthcare (i.e., inpatient and institutional care, medical and surgical interventions, pharmacotherapies, etc.) at the expense of the many socioeconomic support services that bolster the health and wellness of our brethren in other industrialized societies. By some estimates traditional healthcare accounts for no more than 10% of our health status, whereas other factors, including stable housing, income supports, access to nutritious food, genetics and lifestyle habits (e.g., substance use, physical activity levels, etc.), social and emotional support networks and meaningful activity are significantly more determinative of our health and wellbeing (Sederer, 2013). Despite the relatively insignificant contribution of conventional healthcare to overall public health the United States commits 17% (approximately two trillion dollars per year) of its Gross Domestic Product (GDP) to healthcare spending, and it is expected to exceed 20% of GDP within a few years (Johnson, 2012). This is staggering when considered in contrast to an average expenditure (by share of GDP) of 9.3% for other industrialized nations (Organization for Economic Cooperation and Development, 2014). I am convinced beyond any doubt that if Dwight D. Eisenhower were alive today his concerns about our emergent medical-industrial complex would eclipse his fears of the military-industrial complex that proved so prescient in 1961.
The healthcare behemoth is comprised of extraordinarily lucrative pharmaceutical corporations, hospital and healthcare associations, insurers and legions of lobbyists charged to influence public policy in a manner that ensures it commands an increasing share of resources without a commensurate contribution to the public good. It is therefore unsurprising that outcomes of traditional healthcare interventions are dismal in view of our skewed priorities and inattention to the primacy of social and physical determinants of health. By some measures there are at least 11 nations whose public health outcomes are consistently superior to ours despite our extraordinary expenditures in healthcare (Davis, Stremikis, Squires & Schoen, 2014). We realize a paltry (read “pathetic”) return on our investments at both local and national levels. Until recently, New York State committed more resources to its publicly-funded healthcare (i.e., Medicaid) program than any other state, but it lagged behind many in certain outcome measures and languished near the bottom in rankings of potentially preventable hospital readmissions (Office of the New York State Comptroller, 2015).
It is now well known in many quarters that individuals with significant behavioral health and comorbid medical and substance use conditions are at great risk of poor health outcomes and premature mortality. A new behavioral health and wellness workforce must acknowledge its interventions will continue to have limited effect on the overall health status of its recipients unless it reconceptualizes its role in a manner that subverts the current paradigm and challenges the dominant role of its sacred cows, most notably its reliance on pharmaceutical interventions. The pharmaceutical approach to disease management emerged in response to widespread public health crises that resulted from infectious diseases and their associated pathogens (Bland, 2014). Pharmaceutical agents have proven uniquely effective in extinguishing select pathogens and they can be credited with the eradication of many diseases that condemned our forebears to a diminished life expectancy. It is not surprising this approach led to the development of one of the most lucrative and influential industries on the planet. The pharmaceutical industry is the metaphorical hammer that regards all infirmities as nails, and as chronic illness has supplanted infectious disease as the malady of the new millennium Big Pharma continues to strike repeated blows at ever-increasing cost and diminishing returns. An acute-care treatment modality originally tailored to the eradication of disease is now routinely applied to the management of illness. Phenomena we classify as diseases typically originate in one bodily organ or organ system and arise from a verifiable exposure to pathogens or biological imbalances. These are the maladies for which pharmaceutical and other traditional medical and surgical approaches are most appropriate and effective. Chronic illnesses, however, including those in the behavioral health realm, implicate multiple organs and organ systems, arise from myriad biological and environmental causes and require corresponding interventions. Nevertheless, the pharmacologic approach to the management of illness and disease continues to prevail.
Behavioral health and social service providers have witnessed an exponential growth in the use of pharmaceuticals in recent years. Chemical agents that have satisfied the Food and Drug Administration’s (FDA) standards of safety and efficacy are lucrative commodities for their manufacturers who enjoy longstanding patent protections after their products enter the marketplace. Even the most casual and uninformed of observers are cognizant of this, as all of us have been encouraged by countless advertisements to “ask our doctor” if Medication X is right for us. These agents customarily target the symptoms but not the causes of our afflictions. It is therefore unsurprising that individuals with behavioral health and comorbid medical conditions routinely visit their pharmacies with fistfuls of prescriptions and stock their medicine cabinets with droves of agents designed to target primary symptoms, secondary side effects and tertiary complaints that would be more effectively remedied through changes in lifestyle or environment. The conventional approach surely benefits some of its recipients, but it is ineffective on a population level. The most vehement proponents of this approach would concede our nation has never been sicker than it is now in so many respects. Furthermore, this approach is downright hazardous to many. The protocol through which our FDA deems new agents to be “safe” and “effective” is a highly circumscribed one that evaluates each agent in isolation against a placebo and amidst relatively small and homogenous groups of research participants. This protocol cannot be expected to yield meaningful information concerning the consequences of long-term use of individual agents it has deemed safe, nor can it anticipate the potential contraindications of a polypharmaceutical approach to treatment. For instance, a patient who has been prescribed multiple medications for the treatment of schizophrenia, diabetes, asthma, hypertension and hypercholesterolemia cannot consult the research literature on the potential contraindications or long-term effects of his specific regimen. He and his treatment providers can simply learn from his experience and consider the experience of others who once held a fervent belief in the safety of their medications because they carried the imprimatur of their manufacturers. Tardive dyskinesia, Metabolic syndrome, Agranulocytosis, Neuroleptic malignant syndrome and many others constitute the sordid legacy of a longstanding approach that has helped some but sickened others. And few would deny our pharmaceutical industry and the purveyors of its goods are complicit in our national epidemic of opiate addiction. Thus, our conventional approaches to the “treatment” of behavioral health conditions often violate a cardinal dictum of medical practice. They do not simply fail to help the afflicted. They cause harm.
This critique is by no means a categorical condemnation of pharmaceuticals and their role in the management of illness and disease. Many of these agents save lives. Others effect immeasurable improvements in the quality and quantity of years lived. They hold an invaluable place in our expansive arsenal of treatment modalities. But they must be considered in accordance with the aforementioned caveats and innumerable factors that influence the course of chronic illness. An emerging body of research has revealed benefits associated with low-dose pharmaceutical interventions coupled with other biopsychosocial modalities (Carey, 2015). These approaches emphasize the value of social and physical determinants of health to the recovery process and ascribe a more appropriate (i.e., limited) role to traditional medical interventions. These approaches and the orientation that informs them should serve as the foundation on which a new behavioral health workforce is built.
Herein lies the “prescription” for this workforce. It is one that regards individuals in the context of historical factors and the social and physical determinants of health and wellness. It gives secondary consideration to clinical diagnoses, as these are rapidly evolving and culturally defined constructs. They simply enable us to classify individuals’ experiences without understanding or transforming them. Of those entrusted to its care this new workforce must ask, “What happened to you?” It cannot ask, “What’s wrong with you?” Findings of the landmark Adverse Childhood Experiences (ACE) Study suggest an understanding of the deleterious effects of trauma and its repercussions within and across generations is integral to our treatment of behavioral health conditions (Centers for Disease Control and Prevention, 2014). We must also question popular convictions concerning the biological underpinnings of illness and their influence on individuals’ health status. The science of genetics once taught us certain facets of biology were immutable and impervious to environmental influences. The emerging science of epigenetics teaches us of a fluid and nuanced interaction between genes and environment that permits one’s genetic complement (i.e., genotype) differential outward manifestation (i.e., phenotype) in response to environmental influences. An individual who is exposed to early-childhood trauma, viral infections, a poor diet and income insecurity might be inclined to develop symptoms of schizophrenia and diabetes in adolescence or adulthood. This individual might thrive and exhibit no signs of illness if raised in a safe, loving and economically secure household. His genes remain unchanged but environmental contingencies alter their expression. Thus, our new workforce should be comprised of healthcare professionals but in proper proportion to their influence on recipients’ health status, and the lion’s share of our investment should accrue to other professionals, paraprofessionals, individuals with lived experience in recovery (i.e., peers) and emerging classes of practitioners with proven expertise in facilitating recipients’ access to essential social and physical determinants of health. A workforce that can “write prescriptions” for safe and affordable housing, nutritious food, physical activity in open spaces, stable relationships with family and friends, and meaningful activity in the social, vocational and educational realms will address the 90% of the wellness equation for which traditional healthcare has no answer.
It is now incumbent on key stakeholders to garner the resources necessary to support this workforce and there is promising evidence this is beginning to occur. Many states, including New York, have pursued waivers of federal Medicaid regulations that permit them to apply funds toward the provision of services and supports that are customarily excluded from Medicaid coverage. A vast array of psychosocial and rehabilitative services is now available to many recipients, and the Centers for Medicare and Medicaid Services (CMS), the federal agency charged with oversight of the Medicaid program, recently issued guidance that suggests it is open to the application of Medicaid funds toward housing-related support services (Ollove, 2015). This is significant because Medicaid is statutorily prohibited from paying for housing, much to the consternation of many stakeholders who recognize the importance of decent and safe living accommodations to individuals’ stability. Moreover, there is a widespread movement among both public and private payers toward reimbursement of service providers in accordance with the quality of services delivered as assessed by various outcome measures. Such a movement toward Value-Based Purchasing (and away from the Fee-for-Service model that incentivizes providers to deliver more, but not necessarily better, services) necessitates a renewed focus on social and physical determinants of health. If providers’ reimbursement is contingent on the achievement of favorable outcomes they can no longer ignore the factors that account for 90% of their recipients’ health status. New York State has compelled this movement toward Value-Based Purchasing via its implementation of Managed Care models of payment and service delivery that scrutinize outcomes and the means through which they are attained. The state is also in the midst of another grand experiment that aims to reinvest savings in Medicaid expenditures into services and supports that are significantly more community-based and outcome-oriented than the institutional structures (e.g., inpatient institutions, emergency departments, etc.) on which we have relied. This experiment bears the ungainly moniker of “Delivery System Reform Incentive Payment” program, and it aims to deliver payments to coalitions of providers who achieve favorable healthcare outcomes for their service recipients. Like Managed Care and related initiatives, DSRIP presents an opportunity for providers to realign their services and the workforce through which they are delivered in a manner that enhances recipients’ access to social and physical determinants of health. But it is merely an opportunity. Payers, providers, recipients and other stakeholders must properly apply the opportunities afforded via healthcare reform in order for its new workforce and the countless lives on which it depends to flourish.
The author may be reached via phone at (914) 428-5600 x9228 or by email at abrody@searchforchange.org.
