Addressing the Costs of Fragmentation in the Behavioral Healthcare

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					Addressing the Costs of Fragmentation
 in the Behavioral Healthcare System:
         Pediatric Perspectives

                    John V. Campo, M.D.
  The Ohio State University and Nationwide Children’s Hospital
The Public Health Challenge*
Mental Disorders Across the Lifespan
• Highly prevalent
• Begin early in life
  – ~50% with onset by age 14 years
  – ~75% with onset by age 24 years
  – Early onset predicts delayed diagnosis
• Low rates of recognition/treatment
  – 60% receive no treatment

           *Kessler et al., National Comorbidity Study
 The Good News...
• A few treatments for common pediatric
  mental disorders actually seem to work...
  – “A range of efficacious psychosocial and
    pharmacologic treatments exists for many mental
    disorders in children…”
                      U.S. Surgeon General, 1999
• Effects often as robust as in adult studies
The Bad News...
• Most affected youth receive no
  services or get inadequate services
 – “State of the art treatments for
   pediatric mental disorders are not being
   adequately translated or disseminated
   into practice…”
                U.S. Surgeon General, 1999
Plato said it…
• “The greatest mistake in the treatment
  of diseases is that there are physicians
  for the body and physicians for the soul,
  although the two cannot be separated.”
  –   Quoted by David Satcher, U.S. Surgeon General (2004)
More Bad News…
•       MH service delivery often lacks a public health focus
    –     Bias toward office based specialty practice
         •   Specialist convenience trumps public health needs
    –     Poor resource allocation to selected groups and settings
         •   Low income, minority, rural, physically ill youth at special risk
    –     Service fragmentation across the health care system
         •   Separate systems of care/reimbursement/regulation for mental disorders
         •   Collaborative, team based, and multidisciplinary care the exception

•       Shortage of highly qualified MH specialists
    –     Shortage of child and adolescent psychiatrists (CAP)*
    –     Shortage will ↑ at current training/support levels

                                   * Thomas and Holzer, JAACAP 2006
Pediatric Behavioral Health
“Silos” of Self-Interest
• Guild trumps mission
• Control trumps product
• Convenience trumps quality
• “Parallel play” vs.
  multidisciplinary care
• Lack of standardized:
    –   Professional roles
    –   Assessment guidelines
    –   Treatment guidelines
    –   Quality guidelines
Qualitative Solutions
A Roadmap for Success?
• ↑ Impact of specialty MH services
  – Multidisciplinary role definition and clarity
  – Interdisciplinary rapprochement and respect
  – Use of novel technologies
• Integration within general medical sector
  – Bridging specialty and primary care
  – Stepped collaborative care models
  – Integrate MH services within primary care
Why Focus on Primary Care?
 • Resource management and cost control
    – Leverages infrastructure of general medical sector
    – Potential to increase the impact of specialty providers
 • Trust
    – Parents view primary care physicians (PCPs) as resources
 • Practicality
    – Most youth make > one yearly visit to PCP
    – Familiarity and convenience
 • Primary care the de facto MH system
    – Most MH problems seen by PCPs
    – Most MH drugs prescribed by PCPs
Why Focus on Primary Care?
Its Where the Kids Are…


Why Focus on Primary Care?
Specialty Referral Overrated
• Low MH specialty referral rate by PCPs
  – Only one in four identified cases referred
• Limited access to specialty MH care
  – Shortage of specialty providers
  – Administrative/fiscal/geographic barriers
• Poor patient adherence with MH referral
  – Only ~ 1/3 ever see a MH specialist
Why Focus on Primary Care?
Changing Attitudes and Practices
• Health is a unitary construct
• MH in primary care challenges
  –   Stigma for patients, families, and non-specialists
  –   Separate care systems for “physical” and “mental” d/o
  –   Reimbursement “carve-outs”
  –   Provider unease and avoidance
• Physical and mental health overlap
  – Comorbid physical disease
  – Functional somatic symptoms
Qualitative Solutions
A Public Health Oriented Approach
• Bridge existing systems of care
  –   General medical care
  –   Specialty MH care
• ↑ Impact of specialty MH services across systems
  –   Implementation of collaborative care models
  –   MH specialists as educators, consultants, and clinicians
  –   Use of novel technologies
  –   Use of stepped care models
Stepped collaborative care models
Different levels of care depending on illness severity,
complexity, persistence, and response to intervention

                                              MHS in
                         MHS in               Settings
                      Primary Care

       Simple            Complex              Severe
                 MH Problem/Disorder
    Suggested Reading
•   Campo JV, Shafer S, Lucas A, Strohm J, Gelacek C,
    Shaeffer D, Altman H. Managing pediatric mental
    disorders in primary care: A stepped collaborative
    care model. Journal of the American Psychiatric
    Nurses Association 2005; 11:1-7.
•   Kelleher KJ, Campo JV, Gardner W. Management of
    pediatric mental disorders in primary care: where
    are we now and where are we going? Current
    Opinion in Pediatrics 2006;18(6):649-53.