Imagine that you were the director of a health insurance company and you had just agreed to provide health coverage to several hundred thousand people and you will have to fund health care including mental health and alcohol/drug care too. This is called “integration.”
What it means financially is that you will lose a lot of money if you ignore the physical health needs of people with mental health problems. In the parlance of insurance folks, you’re “at risk.”
Now, someone walks into your office and tells you that about a quarter to a third of the people you’ve just signed up to serve are being poisoned but no one really knows about it or recognizes it. If it’s true, you stand to lose a lot of money unless you figure out what’s going on. And what if they also tell you that the poisoning is not some form of environmental pollution like smoky air or unclean water but is actually being caused by the very providers of health and mental health that you’re about to be supporting?
Since you’ve been in the health insurance business for a while, you recognize that in western medicine, almost everything that’s provided is some form of mutilation, i.e. surgery, or poisoning, i.e. medications. (Please note that if you’re a physician and reading this and taking some level of offense, the recognition I just pointed to was made by a physician, a well-respected one at that and he meant no offense, nor do I – just a simple way of thinking about things and the key question is whether the risks outweigh the benefits or vice versa.)
So as you might have guessed, the poisoning is not really recognized for what it is–but psychiatric medications do act as toxins in the sense that they cause many health problems, both in the short-run and also in the long-run–and you will soon be paying for it all. I won’t go into all of the medical expenses that are incurred by neuroleptics, aka antipsychotics, to use just one example, but they include metabolic syndrome which translates to the costs of diabetes, heart disease, and increased rates of cancer. The costs of end-of-life care for people with major mental health challenges have yet to be calculated as far as I know but they are likely to be considerable.
And because you’re a really thorough business expert, you also begin to study up on the effectiveness of the psychiatric medications and discover what unbiased research shows–that they’re not very effective. Most, though not all, people who take them do worse, especially after a couple of years. This adds up to more costs for psychiatric hospitalizations. Finally, you discover that these medications are really pretty expensive but the costs are likely to have been hidden in the public system because the pharmaceutical corporations have lobbied to keep their costs uncontrolled and outside the budgets of many programs.
You have a real dilemma. You’re faced with designing a system and providing funding that could end up costing you a lot more than you’re going to be receiving from employers or the state or whoever is your primary contract funder.
The purpose of this blog is to show the kind of system you would have to design. If you’re planning to be in business for more than a few years. your services would give better results and cost less
What follows is a list of indicators that can lead to focused advocacy in order to make good on the many brave and politically popular promises to integrate care. It is admittedly an extremely ambitious set of standards.
As I noted earlier in this blog, this is a daunting list. No integrated health care system I know of is near meeting very many of them. In fact, I would be surprised if any such system anywhere is meeting even one of them. But that highlights how far we have to go, how little the rhetoric really means, and why we need to begin posing these indicators—the sooner the better.
Robert Nikkel, MSW, is a Clinical Assistant Professor in the Public Psychiatry Training Program at Oregon Health and Science University. He was the State of Oregon’s commissioner for both mental health and addictions from 2003-2008. He is the director of the Mad in America Continuing Education project and a member of the Board of Directors of the Foundation for Excellence in Mental Health Care.