Good morning. Thanks for coming. I know it's bright and early today. My name is Deepika Sastry and I'd like to introduce our talk. It's called Seeking Value, Balancing Cost and Quality in Psychiatric Care. My colleagues presenting with me today are Dr. Wes Sowers, based out of Pittsburgh, Dr. Sosunmolu Shoyinka, based out of Philadelphia. I'm in Cleveland, and Dr. Michelle Joy in Philadelphia. We'll begin with an overview of value, followed by value and quality, followed by incentivizing value through innovative financing and special. I'm glad that nobody had trouble finding seats. So thanks for coming out nice and early to see this presentation. I'm gonna give a little bit of an overview, kind of where Deepika left off. She's gonna be, once her throat clears, she's gonna be talking in a little bit more detail about value and quality. Sosunmulu is gonna be talking about incentivizing value through innovative financing. And Michelle Joy is gonna be joining us a little bit later to talk about special topics related to quality. Then we're gonna end with some discussion. If we have a small group at the end, we'll just kind of have discussion with everybody together. We had originally thought that we might break out into groups, but we'll see how many show up. So just kind of giving an overview of value, and we developed a book called Seeking Value, Balancing Cost and Quality in Psychiatric Care. I'm gonna tell you just a little bit about how that came about. We're all members of the Mental Health Services Committee at the Group for Advancement of Psychiatry. And over the past 10 years, we were working on a variety of projects. And one of the things that began to kind of make sense to us was that we saw some common themes in many of these projects, and they were mostly related to how we improve quality or how we reduce costs and waste in the system. So they were value-based issues. And we also noted that there was kind of a lack of literature on psychiatry's role in value management. So first of all, we were just thinking about the idea of value and what it is. How do we think about it? So value is the ratio of quality over cost, or as we think about this in colloquial terms, it's getting the biggest bang for your buck. And so we have to think about how we measure quality, what kinds of things indicate quality, and how do we measure cost? What do we include in that equation? And there's also values, what individuals or groups feel is important, desirable, or important to them. So we also need to think about who decides what costs and what values should be determined. So in thinking about this and trying to begin to put together an idea for a book, we wanted to think about how our systems evolved and where we stand at the present time. How is emotional health related to overall health and population health? What factors are relevant, and how do we maximize value? So we began to think about shaping our book, and we thought about this in four major kinds of ways. Where we've been, you know, and thinking about why U.S. health care has delivered such low value. We wanted to talk about where we're going or where we need to go in terms of both systems and professional interventions. And thinking also about special opportunities to find value. And these are kind of non-medical influences on health outcomes. And finally we wanted to end with a vision for how we might reform our health care systems. So I'm going to just go into a little bit more detail about these sessions. In the section on where we've been, we started, we wanted to start by defining how we think about value and how we measure it. The evolution of quality and cost management. Looking at our current system and basically the mess that it's in. We wanted to think about the socio-political determinants of health. And also looking at those initiatives that addressed value and did so effectively. So, you know, obviously, you know, when we look at our current system, there are a variety of things that affect both cost and quality. So it's very fragmented. We have a profit-driven, predominantly fee-for-service system, in which we spend a lot of money and get very poor outcomes. We focus on individual versus population health. We focus on disease rather than health itself and prevention. There's a great deal of administrative waste in our system. Our education system is rather limited in its scope and doesn't prepare people, doctors, to think about value. And we have a system that also ends up leaving graduates with a great deal of debt, which contributes to inflation of compensation. And malpractice also plays into the expense side of the equation also. In thinking about socio-political determinants, you know, just basic needs, housing, income, access to health care, education and employment opportunities, environment, what causes distress in communities and to individuals, and injustice and oppression, and how all those things really affect population health. So we wanted to begin to think about how we start to fix this system. And so on a systems level, what kinds of financing we could consider that would improve value, how we could better integrate services, focus on prevention, how we might use peers and mutual support to improve people's tenure in the community, and also how we might employ technology. We also wanted to think about professional interventions, what we can do as psychiatrists. The scope of practice for psychiatry has narrowed considerably over the past couple of decades, primarily focusing on pharmacologic treatment. And so we talk about, you know, the way that we need to expand the scope of practice, and the psychiatric workforce, and who is included in psychiatric care. How we can better manage pharmaceuticals, which may be in many people's estimates over-prescribed, partly because of a very complex diagnostic system, which seems to pile a variety of diagnoses on people, and so over-diagnosis and over-prescribing are a result of that. And we also wanted to think about how we can be better advocates and leaders to help initiate and achieve some of these changes. So finally, we end with a value vision for health care reform, principles of reform to achieve value, models of organization and financing, tools for managing resources and quality, strategies for improving value, and we kind of defined three tiers of intervention. And I'm just going to go through these very briefly, because part of what we want to do at the end is get you guys to think a little bit about how we can make progress along some of these changes to our system. But Tier 1 is a relatively simple constituency with relatively low resistance, and these are things that we can do on a professional level. Tier 2 has a more diverse constituency, the system in general. There's kind of more moderate resistance there, more stakeholders involved. And Tier 3 is very complex, because it involves a great number of stakeholders, and so there's going to be a high resistance to change. And these things have to take place on a political level. So I'm not going to go into detail on these. These are things that we're going to get into as we continue this morning. But I did show you the book, I think, in the beginning. Okay. So next, hopefully Deepika is recovered and can help us with this next session. So forgive me earlier for hacking up along. It's not COVID. I wouldn't be here otherwise. But welcome to our talk. Thank you, Wes, again for providing your overview. I'll be focused on quality today, and I think Wes had mentioned the value equation is quality divided by cost. So I'm going to focus on that top part of the equation. I'm going to do a little bit of history to start, a bit of an overview, and then getting into quality. What is it? How do we measure it? How can we make things better? So why history, right? I'm a firm believer that in order to know where we are now and where we're going next, we have to understand where we've come from. And a big reason for that is value is intimately tied to our values as a society. Namely, when it comes to mental illness, for thousands of years, there's been stigma around it, ranging from fear to punishment to loathing, ostracizing people with mental illness, locking them up. And, you know, it makes you wonder, you know, we think about how far have we come since then, but understanding that how we view mental illness and substance abuse ties directly to how we treat these individuals, and just as importantly, how much we're willing to invest money in treating them. So in the United States, I'll focus on just the US. It's a pretty broad topic. Stigma persisted for a very, very long time, pretty much well into the late 1800s. And it was only then with the arrival of activists and reformers like Dorothea Dix, et cetera, where people began to push for the humane treatment of the mentally ill. This led to asylums and institutionalization. I think we consider asylum to be a pretty pejorative word these days, but back then, asylum was actually a term for sanctuary. It was intended to be a place of refuge, a place of long-term treatment for those who were mentally ill. So a bit archaic now, but wanted to make sure the word was there because that was prominent. I'll go into then deinstitutionalization, followed by the more modern era. So deinstitutionalization, in a nutshell, was basically the moving of patients from the state-run facilities, asylum state hospitals, into community-based treatment. So the two pieces of legislation that I put on the slide there were the main drivers that enabled the movement of, as you can see by the quotes, over 600,000 individuals in those settings into the community. Between the 1963 Community Mental Health Act and the 1965 Medicare and Medicaid Act, we saw an exodus. And therein also lay the problem. While there was federal funding for over 2,000 community mental health centers, there was not adequate infrastructure. There was not enough funding for staffing, for administrative support. So as you can imagine, there was a divide between what was expected and what actually transpired. But something to remember that this, on the surface, I think can seem like, oh, we want to give people humane treatment, give them their autonomy, give them their freedom, but we didn't provide adequate resources and support. And to this day, we do see that a dearth of psychiatric beds still exists now. In fact, so much so that there's a bit of a crisis around that. Deinstitutionalization, the last thing I want to say about it is, it's a gradual process. You cannot undo hundreds of years of institutionalization in 60, maybe going on 70 years of deinstitutionalization. This type of change is broad and it takes a lot of time. Moving into the modern era, we have the evolution of biological psychiatry with the development of medication. So lithium was developed and used in 1948, Thorazine in 1952, followed by Prozac Nation, SSRIs, SNRIs, and so on, atypical antipsychotics in the 90s, 2000s, as you can see. But medication is just one piece of the puzzle. Just as important in psychiatric treatment, as you well know, especially those who are severely mentally ill, is psychosocial rehabilitation. So I included the concept of recovery, which came about in the late 90s, early 2000s. The idea being that people can recover from mental illness, that the individual's own agency, self-determination, and hope play a large part in owning their illness and being able to live a fulfilling life. Some of you might recognize that picture, if you're from New York City, that's Fountain House, which is the largest clubhouse in the world. It was started in 1948 and it still survives to this day. I'm going to skip this slide and move to this one. I expect you to memorize this slide. There'll be a pop quiz at the end. I'm kidding. Managed care, so our favorite topic. Suffice it to say, I wanted to include this slide because managed care is also part of the history. It began in the 1970s as a way to curb and contain cost. MCOs, managed care organizations, were seen as a gatekeeper, a way to manage treatment within a defined network of providers, PPOs, HMOs, again with the focus on cost containment. Very, very controversial, a lot of restrictions within MCOs. I'm sure you're all aware of this. It did result in some legislative reform in the 80s and 90s trying to curb the power, so to speak, of MCOs. But at the end of the day, have they curbed costs? The answer is no. Health care costs continue to rise. This was one effort to attempt to contain them. Last but not least in the history section, I wanted to talk about the Affordable Care Act. It actually began, the precursor was 2008, the Mental Health Parity and Addiction Equity Act. ACA built off of this and was passed in March of 2010. ACA, so pros and cons, right? The basis of this slide is I wanted to talk about the legacy of the Affordable Care Act. Did it do what it set out to do? Yes, in a way, right? It did lead to a decrease in the number of uninsured. As of 2022, 35 million Americans are enrolled, have enrolled in Affordable Care Act plans through the health care exchanges. But there are cons, too. Premiums have become higher because insurance companies have to cover a wider range of benefits. The networks can be limited. Businesses have found a way to circumvent the ACA by reducing hours of their employees so they don't have to provide coverage. But the reason I included this is it goes back to values, our values as a society. The Affordable Care Act was the first real step towards universal coverage in this country, something that is prominent in other nations. If we truly value our citizens, health care should be a right and not a privilege. I'm going to go back now, if I can figure out how to go back, to the previous slide. So forgive me, I'm going to editorialize. Better to ask for forgiveness than beg for forgiveness, ask for permission. So, one second. As of 2020, how much are we spending on mental health care in the United States? $280 billion. It looks like a big number. But if you look at it compared to the GDP, it's less than 1%. So as of 2021, national health expenditure in this country was 18.3% of gross domestic product. We're pretty high up there. But of that, mental health spending is less than 1%. That number has not changed in 40 years. So in other words, mental health spending has not grown proportionately as a share of national income in this entire time. So what the numbers also don't show is the indirect cost, the societal cost of mental illness, right? So what about the time spent in loss of productivity? I think there was a 2018 study that showed that loss of productivity was estimated at $80 billion. So you don't see that captured here. What we do know is also since the pandemic, mental health in this country has been on the decline. There's a workforce shortage. One in five adults in the United States lives with a mental illness. And I think I just read the statistic yesterday, nearly 50% of Americans experience a mental illness at some point in their lifetime. So if these numbers don't tell us we need to invest in mental health in this country, I don't know what does. But why, right, the bigger question is why is it this way? And as Wes had talked about, the mess we're in. A large part of it is that we've got a fragmented system. It's insurance-based, fee-for-service, multiple sources of payers, multi-payer, hybrid system. So, all over the place, what is interesting, and I'll talk about this a little later, is the largest payer of services, mainly because of the Affordable Care Act, is Medicaid. Medicaid accounts for 25% of the mental health spending for services in mental health in the United States. It's pretty staggering. So, again, going back to values, do we not spend on healthcare because we don't value our citizens? Do we not care about mental illness and substance use disorders? I think that's kind of perfunctory. I think it's important to take a step back and see the big picture, that it's much more complex and multifactorial. Until we begin to really place emphasis on not just treating these illnesses, but treating the impact of these illnesses on society as a whole, things, I don't think, will move forward. Now, my favorite topic, quality. I don't know, can you guys read this? If not, I'll read it. Yeah. I know Dilbert came under some criticism, so I apologize, but I still enjoy the comic. I've improved healthcare quality by 19%. Well, what is healthcare quality? I don't really know. Well, then how do you measure it? I wasn't expecting questions. All right. I'll go through this history part pretty quickly. The main player here is Dr. Avedis Donabedian. He's an epidemiologist and is widely considered the father of quality in healthcare. I'll go through his model a little bit later, but as you can see, the concept of quality in healthcare has been around since about the mid-1800s. I want to start with the Institute of Medicine. It's pretty recognized as a leader and a national advisor in healthcare, and go through their definition of quality. There's six parameters and six domains of quality. So we'll go clockwise, starting on the top right with effectiveness. Effectiveness is how well does a service achieve its purpose? So, for example, remission rates in depression, in antidepressants, say, versus TMS, versus ECT. The second one, patient-centered treatment. Pretty self-explanatory, right? But understanding care from the patient's perspective. In our arena, it's starting by asking a patient, what are your goals for treatment? Timeliness is the third one. Providing services as soon as possible. So you could measure, for example, the time it takes to get an initial consultation in a clinic. The fourth one is efficiency. How well does an organization utilize its available resources to produce an output? So, for example, average length of stay for an inpatient admission is an example of measure of efficiency. Equity, again, harder to define, but essentially no one group of people receives better care than another group. And safety, last but not least. Taking all steps to protect patients from harm, including prevention of medical mistakes, injuries, and so forth. Building off of this is the Institute of Healthcare Improvement, the IHI. Back in 2007, they actually came up with the triple aim, and then in 2014, it expanded to this, which is the quadruple aim. So the difference between this and the IOM's definition has to do with being more patient-centric. So the quadruple aim takes a look at, for example, what is the patient experience? Another component is the health of populations. So public health, prevention fits into this category. Another aim is reducing per capita cost. And finally, the one that was added last was healthcare worker experience. If we cannot have workers who are, if we can't have professionals who are satisfied and reduce levels of burnout and moral injury, we will not have satisfied patients. Okay, moving on. QI. So quality improvement is hard to define. I took two definitions here, and I actually like kind of the combination of the two of them. One is from the National Academy of Medicine. The degree to which health services for individuals and populations increase the likelihood of desired health outcomes. Emphasis on desired health outcomes, and then consistent with current professional knowledge. The Centers for Medicare and Medicaid Services also have a definition, and I like what it says about the framework used to systematically improve care and seeks to standardize processes and structure to reduce variation, achieve predictable results, and improve outcomes for patients, healthcare systems, and organizations. Excuse me. So quick editorial. I apologize. Sorry. Quick editorial. QI. It sounds really good on paper, doesn't it? It can be viewed sometimes as being top heavy, coming from top down. Feels like another thing to do. And also, I don't know about you guys, but I read that second definition. Thank you. And I thought, are we in a factory? Are we making widgets, right? I mean, healthcare is complex. It is not predictable. We can try to standardize processes and structure, but is this attainable? So just food for thought. CQI, continuous quality improvement. So unlike QI, CQI is much more team-centric. So the key is that it relies on input from all the stakeholders in the system to work towards a unified common goal. And this is why it's hard to do. I wanted to show you the PDSA cycle, which is one of the models for quality improvement. So as you can see, we start with planning. And planning involves, and this is the key, honestly and objectively appraising a current system, like really being willing to look at the flaws in the system, followed by identifying areas of improvement, the doing, committing, committing as an organization to implementing the changes, and then studying and acting, continuously monitoring the performance over time. And the process continues. So continuous, it keeps going around and around. It's systematic, continuous actions leading to measurable improvements. So like I said, easier said than done. Why is it so hard in healthcare? Well, a big reason is because there are multiple stakeholders. You think about an inpatient unit, right? You've got the psychiatrist, you've got a social worker, you've got a patient, you've got a patient's family, you've got therapists on the unit, nursing. And ideally, yeah, they all, you know, we wanna say working towards a common goal, but the ways in which they might achieve that are different and might be in conflict with other members of the team. So CQI requires that there is a coordinated team, a team that trusts each other, works together, and they participate in a way that allows working toward a clear and strong vision. If CQI is not done properly, it comes across as another thing in your to-do list, doesn't it? It's just another thing to do, when in reality, it can be a really, really powerful tool if you have all the players on the same page. You know, I think in healthcare, it's akin to herding cats, but I read a quote that said the best way to herd cats is to get them to chase after the same mouse. So you want to be able to find a common and unified goal, and I can't stress this enough, get buy-in from all the stakeholders. Every member of the team is valuable. No one is less than. Otherwise, you end up with, I think you can see these cartoons, patient-centric care, right? Where's the patient? And the other cartoon there. So outcome measurement. So how do you measure quality? This is the Donabedian model that I was referring to a little bit earlier. So he's well-known for coming up with these three elements of outcome measurements, structure, process, and outcome. So structure, we measure an organization's capacity, their system, the people involved. For example, a structure could be the ratio of staff to patients on a unit or in a clinic. Process measures what an organization does to maintain or improve health. So what you might see in public, a press release, is really the process piece of it. So thinking about a percentage of people who receive preventative mammograms, for example. That might be something that you'll see out there in the press, that's the process piece. And finally, outcome. These are measures that reflect the impact of an intervention on health status. This is the gold standard. We want to make sure we know what the outcomes are. Examples of outcomes, pretty definable outcomes, are things like maternal mortality rates, infant mortality rates. In surgical cases, rates of surgical errors, that type of thing. Ways to measure outcomes, this is my final slide. There's multiple different ways. I wanted to highlight the difference between quantitative and qualitative. It's pretty self-explanatory, but you want to utilize both of them. Program evaluation is basically like a continuous quality improvement. It's a systematic way for collecting and analyzing and using information to answer questions about policies and programs. Is a program effective? Does it serve its purpose? Is a program efficacious? Does it work day to day? And then is it cost effective? So those are three examples of something, that a program evaluation might look into. I included social determinants of health here as well, because it, again, ties back to this idea of values. Excuse me. The indirect costs of mental illness are related to social determinants. Things like poverty, lower educational level, income. Good morning. Thank you, Wes and Deepika, for laying a really good foundation. My name is Susumu Shoinka, and I serve as the chief medical officer for Philadelphia's public mental health system. I'm a psychiatrist by training, and I have an MBA from Kelly School of Business. What I'll be sharing with us this morning is talking about how financials, the way reimbursement, payment, healthcare financing shapes our behavior as providers, but even more so how that impacts the way health systems behave. And then we'll talk about some of the reasons why the fee structure, the payment structure, reimbursement structure here in the United States has taken the forms that it has. And we'll also talk about some of the potential iterations, innovations that have begun to be made in payment, in healthcare financing, and the potential for those reforms to change the way services are delivered and thereby improve outcomes. So I'm going to pause for a moment. Before I go on with my slides, I'm going to ask all of us, it's morning, it's Monday morning, it's a heavy subject. So let's tie this to our experience very quickly. Let's pause for a moment and think about your worst job ever. Let's think about it for a moment. And just think about that with me. Mine was as a senior household, I trained in England before I came to the US, and I had a brief stint, locum stint, where I absolutely loathed the job. It was, thankfully it was brief, but there was nothing right about it, the environment, the leadership, and so on. But I stuck with that job for the duration of time that I was assigned to it, because I really needed that paycheck at that point. So I'm going to invite you to do the same with me. Think about your worst job, or your least favorite job, and what kept you behaving the way you did, which is get up, show up, get up, go to work, and why you stuck with it that long. That is a personal analogy, or a personal application of the way financials, or finances, or financing shapes behavior. Now, there's been a lot said about health systems, and all the concerns that we all have about them. Well-founded, there are no perfect systems anywhere in the world. But we have the one that we have, and I think it behooves us to think about why the systems act the way they do. Now, Wes and Deepika have both talked about values, and the way values drive value, basically define how we think of value. How do we decide what's most important, and does everybody, do all stakeholder groups define value in the same way? So we'll talk about that. Talk about also, I kind of introduced this already, how healthcare financing drives behavior. We'll talk a little bit about current financing models, and Wes and Deepika have talked about this a little bit already. Primarily, the dominant primary way that health systems and individual providers are rewarded is through fee-for-service, and there are good things about fee-for-service, but there are some serious challenges with fee-for-service. And then we'll talk about future models of financing healthcare that really do have potential, and we'll talk about an ideal future state, or a proposed ideal future state. So what are some of the values that drive, that are at play, I should say, in the U.S. healthcare system? The first is the question, is healthcare right or a commodity? Now, when you look at, when you take a step outside the U.S., and you look at other advanced countries, many of those countries have made the decision at some point that, as a developed nation, we consider healthcare to be a fundamental right of all citizens, in the same way that we consider safety, and a right to education, and a right to protection, and all of those things, as to be a fundamental right. And I'll ask you the question, in the U.S., is healthcare considered a right or a commodity? And the, I would argue that it's considered a commodity to be bought and paid for as you are able to. Another value that's often in tension in the U.S. is the role of government. Now, I happen to work in government, but before that, I worked in for-profit managed care, and I served as a medical director for two health plans in Missouri and Kansas simultaneously, and so I got to see the world through those lenses. Well, there are those who argue that the role of government should be small, and limited to the barest minimum in terms of regulation, perhaps, or minimal regulation at that, and there are others, and you see this at play in certain states, where the government really has a pretty strong role in regulation and setting, essentially, the rules of engagement. But those tensions have persisted, and you can see them at play continuously in the national discourse. We certainly saw them really come alive in the discussion around the Affordable Care Act, and so on. And the other question is, who defines value? Through whose eyes should value be defined? And if everybody, if different stakeholders have an equal stake in the system, whose value should predominate? So let's pause for a moment. I assume most of us here occupy the role, much of our time, as people who are delivering services, providers, physicians, clinicians, primarily. Well, what's our value? We go into medicine for a certain set of reasons. We want to be healers, and fundamentally, we also want to make a good living, as good a living as we can manage. Well, for the person that's seeking services, what are their values? What is most important to them? Well, people want to have access, right? They want to have access timely. They also want that service to be of good quality, so I want not to be hurt, primarily. And I also want to hopefully get that service at a decent price point. I don't want to pay excessively for the care that I get. And I imagine those would be common to many people. But the issue is that these values all occur in tension, and so a lot of the complexity that we see in the healthcare system is driven by this. Who pays? How much do they pay for? Who makes the decision about how much is enough? And what's the recourse, if I don't agree that that's enough? And then there's the question about costs versus quality and flexibility versus accountability. So there's a lot, the main point here is that there are a lot of values at play, and those values, or the conflict between those values really drives the complexity that we see. Let's talk a little bit about the pay-for-service model and some other models of reimbursement that are at play right now. So we all know about the pay-for-service. It is the call that I would get when I was an intern in the morning and calling to the insurance company to say, hey, please give me permission to treat this person. And then two days later, somebody will call me and say, hey, look, did you adjust the medications? That's basically pay-for-service. It's a unit, it's a predetermined payment for a predefined unit of care. And then we have to ask the questions about how those things are determined. But some of the challenges are that on the plus side, it does ensure accountability. So if I can account for 15 minutes of care and prove that I delivered 15 minutes of care, then I can get paid essentially the market rate for that 15 minute unit of care. So that's accountability and it's important. The downside is that some of the downsides are number one, it does obviously incentivize volume. So if I am going to be paid for just delivering care and that payment is divorced or detached from the outcomes of that care, then I might as well do as much as I can regardless of what the ultimate outcomes of that service is. One of the other challenges with fee-for-service is that it restricts flexibility. I will give you an example from something we all experience commonly. Historically, particularly for the SMI population, there is a whole gamut of activities that are necessary to ensure that their care is coordinated because people typically have very complex needs, medical needs, behavioral health needs, oftentimes social needs. Well, somebody has to take the time to put all those pieces together and because of the fragmentation that's been spoken about earlier, that's not an easy task in the best of circumstances. Well, if that service is not paid for or covered somehow financially, if it's either not agreed upon that it's a service that should be paid for or the payment for the services is insufficient, that becomes a disincentive. That is essentially that discourages providers from doing that, which then means we fall into some of the things that we see commonly happen. People fall through the cracks because they're not connected to services or nobody's following through on their care. That's just one manifestation. You see this play out outside of behavioral medicine in various ways. Some of the other payment mechanisms that exist right now, we have prospective payments and you see that in some new models of care, we have episode of care things like case rates. I got very familiar with this when I was in managed care, capitation, bundle payments, and global payments, which are like gigantic payments for a population oftentimes. Well, because of some of the challenges that we talked about earlier, people have started to attempt to refine or experiment with new payment models that address some of the challenges we just talked about. They are, as a group, referred to as alternate payment models. Some of these are fairly new. Some have been around for a while. Most people are familiar with MACRA and MIPS. Some people may be familiar with shared savings, which essentially means that if I, as a payer, come to a provider, perhaps an inpatient provider, an outpatient provider, and I tell you, look, if you do a good job of managing the care of these patients, so this group of patients, well enough that we save money at the end of the year, then I'll split the savings with you. It's an incentive. Pay for performance is another one such incentive. It's probably the lowest in terms of complexity as far as alternate payment models. It basically means if you hit these metrics, these few one or two things that are quality outcomes as measured by data that I'd like you to hit, then I'll pay you for it. One example when I was in managed care was we looked at our SMI population and we said, look, people with SMI are known to die from cardiovascular causes much earlier than their counterparts. Well, the problem is that one of the reasons why they die is because they don't get screened for things like diabetes and hyperlipidemia and high blood pressure and so on. So we'd go to a CMHC and say, look, this group of patients we know you're caring for, if you will screen all of them, you know, at the end of the year we will pay you this amount. And that's sort of how that works. Accountable care ACOs, accountable care organizations, it's not really an alternate payment model as much as a way to assign comprehensive care to a defined entity. So basically what that means is a payer would approach an organization and essentially hand over the care of that defined population to them and say, hey, look, if you can coordinate all of their care and make sure that we hit our quality metrics, hit our financial metrics, then we reward you for that. Now, there are alternate payment models that have been tested specifically for mental health, populations with mental health needs. Those include risk-adjusted bundle payments. New York has an example. The city of Baltimore has an example for that. Basically, they look at historical spend on their most expensive patients and then they pay, including housing, social cost, social service cost, and so on. And they basically will pay a provider to ensure that those costs remain contained. And then you have PCOAT, which is a new bundle payment for treatment of opioid use disorder. It includes three different phases. It includes the induction phase, maintenance phase, and transition phase. All right. So, continuing with that trend of innovation in payment, there are new ideas that are being floated. One example is value-based insurance design. What this basically means is using, to some extent, what's called behavioral economics to shape the behavior of the insured population so that that population tends to gravitate towards the more value-yielding activities, such as preventative care, such as choosing to use an assigned provider rather than out-of-network providers. And then HMOs increasingly are beginning now to incorporate social determinants in their payment methodology. You see this with organizations like Geisinger Health Systems, which has both a payer arm and a provider arm, and beginning to recognize that, you know, what happens in a person's life outside of the clinic in their, you know, day-to-day lives really does impact their overall well-being. Now, so, in thinking about the future of behavioral financing, there are some opportunities that we have, and these are, we can call these a moonshot, basically, in some respect. So, universal coverage, you know, would be helpful. Yeah, setting aside all the, you know, heated discussions that often accompany that, but it would be helpful. Certainly it would eliminate some of the downstream impacts that we see of untreated illnesses, right? It's more effective to provide access so people get care earlier than later. Access for all would be ideal as well. Addressing socioeconomic determinants, we increasingly, there's increasing attention to that. Ensuring high-value care, which basically means, for us particularly in behavioral health, scaling up evidence-based, the deployment or routine use of evidence-based care at the population level, at the health system level, at scale. And this is not, some of this is actually being done in some health systems. In Philadelphia, for example, CBT and other EBPs have been implemented at the system level through using implementation science for years now. So it's doable. Not easy, but it's doable. Cost containment would be, is also necessary because all systems without the sort of continuous quality measures that Deepika mentioned will eventually tend to waste. Particularly when we think about those values that we talked about earlier, you know, self-determination, you know, best care and so on. There has to be some system to ensure that there's no waste. And then quality oversight that includes the experience of those with, or perspective of those with lived experience is essential. And this would be a holy grail. And I will stop and hand it over to Michelle. Thank you. Thank you guys. I missed the introduction because I was speaking next door. So I will just say briefly, my, I guess, work, you know, stuff is up there. I'm at the VA. You know, we always say I'm not speaking on behalf of the VA or federal government. But other than that, yeah, I'm an emergency psychiatrist, a schizophrenia psychiatrist, for the most part, an outpatient and a forensic psychiatrist. So what I wanted to do with this talk and, you know, as a part of this book, my own chapter was on criminal justice reform. And so kind of taking what everyone else talked about today and using that as, you know, kind of a case example to go through in terms of how we can think about value in terms of, you know, the mental health care and other, you know, components of how mental health is involved and should be or shouldn't be, in fact, in terms of, you know, the criminal justice system. So as an example, right, we talked about value. How do we define value? And what are some other correlates and kind of ways to think about this? Well, for the criminal justice system, what is value in the criminal justice system? So not as psychiatrists necessarily, right? But what is the criminal justice system kind of founded on? What are these kind of penological principles and what is considered when, you know, people are building jails and prisons and, you know, everything that's kind of considered in, you know, investing all of this money, which we know is a significant amount of money, into these structures? So, you know, it's pretty laid out for a criminal justice system. And I'm specifically talking about, right, incarceration and being behind bars, but it is somehow expected or thought about that, you know, it might deter people from future crimes on an individual level or a population level, that people are isolated, you know, and therefore cannot commit crimes in their communities. Though, of course, there is a significant amount of crime in jail and in prison, that there is a punishment, you know, aspect, that there is restitution to society in some sense, but there we are, right? Like, rehabilitation, is that an aim of the criminal justice system and how much can it be so? And is that the role that we play? Similarly, you know, describing costs, I mean, this could be its entire own talk, this little part right there, but, right, what are some of the costs beyond just financial of, you know, incarceration and that social disruption to individual lives, family lives, community lives, right? Reinforcement of anti-social behaviors when people get locked up and spend time in jail and prison, you know, they are learning to live and be a certain way for survival. And so, if we're actually talking about, you know, some rehabilitative aspect, how does that play out? And that goes on and on, right? So, there's trauma there, mental illness can be exacerbated, you know, or caused, really, to say the least. All the data on, you know, incarcerating people does not necessarily indicate that it decreases future crime. You know, there's actually some, you know, studies that it's relatively, you know, kind of limited in a sense of when that's true that it decreases recidivism. In some cases, it might be about equal, and in some cases, increase recidivism. And like I said, so, like, this is, you know, taking these thoughts about how to define value to a particular system. These are the kind of granular contexts we're going to talk about. And again, right, are we talking about an individual? Are we talking about a family level? Like, how are we defining which values? How are we describing these costs? And how are we adjusting the scope of this? Because, you know, these kind of broad values that the criminal justice system is, quote-unquote, based on, you know, how does that affect the individual family where, you know, for three generations, someone's been locked up, right? Or how does that define the individual block or part of a city where, you know, they don't have voting rights necessarily, either, you know, our felons in Pennsylvania don't get to vote, or they're, you know, the young black men in this part of the city or the city are out, you know, are removed outside and cannot vote and contribute. So, these are kind of the things that we think about in kind of narrowing, defining the scope and values and costs. And so, in psychiatry, what is it, right? So, you know, I'm kind of reiterating some of what I said before, but, you know, we are looking at, for the criminal justice system, it's a very fragmented system, right? Can we even describe it as a system of care? I don't know, but we know, you know, it's driven by profit. There's a lot of privatization in these contexts, and some of that is from, you know, litigation, but that's, you know, in some part independent of what we're talking about. They just, they're huge institutions that take a lot of money to run and a lot of staffing and everything like that. So, how do we position ourselves in this system? Again, you know, thinking about values, costs, and our role, are they, you know, what, how do values come into conflicts, right? Are they rehabilitative? Can they be rehabilitative? What could our role be in this? And, you know, do we have a role in a system that might be founded on, right, penological kind of principles, if that's their fundamental route of justification? And so, you know, going back to some of the earlier talks, like these are socio-politically determined. We're thinking about all of these factors that go into it that we don't treat one-on-one in the clinic. Poverty, housing, you know, all of the kind of things I won't even list right now, but these are the things that we have to consider as psychiatrists, not even as a correctional psychiatrist necessarily, and going into this space where we might be treating someone behind bars, but again, thinking about this bigger picture and what role we might have in not only providing clinical care, but kind of evaluating as psychiatrists. So, what is the potential for rehabilitation in jail, in prison, which are very different systems to begin with, right? Like jails, in and out, in and out, withdrawal, kind of management, get someone out, and then prison, someone might be there for decades. So, kind of, what is the potential for rehabilitation in these contexts, and how are we weighing that, you know, in terms of of these costs and values? How are we weighing that with both negative effects on, potential negative effects, right, on society and on individuals, and including in some of these things that we do have kind of direct domain over, right, like behavioral patterns and things like that. How does time in jail or prison then affect someone's, you know, anti-social behaviors and things like that? So, what we come out of it with is, if we are going to put more value into the system, we kind of go back to those aims and figure out where we can fit in and how we can, you know, provide the most value based on values that can achieve some of the aims, if not all of the aims, and kind of defining the scope of that. So, what does that mean? My chapter in the book is a lot about kind of taking a public health approach to these questions, about reducing not only crime, but kind of, if you think about, right, primary, secondary, and tertiary prevention, applying that to this context. This is kind of going to be the scope that we look at these values and, you know, aims and costs, and that's how, you know, I'm framing this, considering the criminal justice system for this intervention. So, if you think about it, wow, my own psychiatrist is calling my cell phone right now. If you think about it, right, so you could say primary prevention, we're going to stop crime before it occurs. Secondary intervention, we're going to stop recidivism, and then tertiary is something like controlling, actually, the harms of being behind bars or incarceration. So, to do that, you know, looking at these kind of model programs and evaluating them, as we've talked about in some of the earlier, you know, talks from my colleagues here, what are the rehabilitative goals of individual programs that can achieve this? How are they financed? How do they fit into the overall system, not just the criminal justice system? And, again, like, what are service users, patients, clients thinking about their value themselves, too, right, because that those are populations that define value themselves. So, just looking at time, and so what's a way that, you know, taking these three steps and thinking about them with regard to value and cost, right, so primary prevention, how are we going to prevent crime on a population basis when we're thinking about adding value to a system? It's going to be proactive, of course, public health, when it's prevention, right, not a public health orientation. It's largely outside of the system of punishment, right, because nothing has happened yet, but overall, you can kind of include it in these calculations because it tends to be cost effective on an overall systems level, and that's where, you know, as they were talking about universal payer systems, I mean, even outside, like, this is not in and of itself a healthcare system, right, but just thinking about, yes, if you want to define cost effectiveness of something like incarceration, you could limit it to the scope of how, you know, this jail makes money, right, but when we spread it out over a broader level, like, what are the interactions between what we call the mental health system and the criminal justice system with how we regard cost effectiveness, and the more integrated our systems are, and the more they have, like, not even just shared values, but shared language about cost, you know, you can kind of make some of those determinations, but overall, it's thought to be cost effective. Focusing on youth, obviously, we're talking about prevention, and I don't know about other cities where y'all are from, but in Philly, you know, so much of the gun violence right now, in particular, is with the youth, that's, like, been one of the major trends of violence in our city, so emerging adult populations, 18 to 25, but also juvenile populations, too, and so, you know, starting to focus on these things before, right, as a primary prevention modality before they start, so what are the targets, you know, considering all these values, considering what we've talked about in terms of scope, and, you know, cost, and, you know, those values that we want to come into, you know, thinking of rehabilitation, but not really, because it's before it happens, but we're going to, you know, target antisocial behavior. We tend to think of antisocial personality disorder as this thing that is, you know, not adjustable, because it's a personality disorder, we don't have mental health interventions, this and that, but there actually are interventions and data around specific antisocial behavior in youth, right, before it becomes a personality disorder. Gun violence, that's the talk that I was just giving next door, just on, you know, ways to reduce gun violence overall. Substance abuse, we love to say as psychiatrists that there is not an association between severe mental illness and violence, or if there is, that people are more likely to be victims than perpetrators, but there are still things that are associated with violence, including firearm violence on a psychiatric level, and so some of that is substance abuse, like alcohol is really tied to it because a lot of people drink and it's disinhibiting, on a population level, that's one thing, to treat, on an individual level, stimulants, like meth really, really increases someone's risk of violence, so these are the kind of things that we go through and think about, where are we putting, if this is our value, where are we putting our time and money? Secondary prevention in terms of recidivism and reincarceration, again, we're kind of thinking about not only the ways that incarceration is going to be influenced in a cause-oriented manner, but also the influence it will have on sociopolitical determinants of health, so again, secondary intervention in this model, for the public health model, is to talk about decreasing future crime, and so how do we do that? A lot of that is going to be through diversion from incarceration into treatment, and so there is, the first of the listed approaches is the sequential intercept model, and all the other ones are kind of pieces that could be along those lines, but how do we really take people that have been already accused of a crime and kind of decrease these harms, while again, thinking about our values of rehabilitation before it becomes rehabilitation, and so, not to get into the entire model, but basically diversion at different intercepts between contacts with police, to supervision through parole and probation, and so crisis intervention, and the ones I've listed here, these are kind of model programs, including the descriptors on how we would define kind of model programs from this way to approach cost and quality, so crisis intervention has some data around that, just really having early and accessible treatment, we'll say that kind of over and over again, in terms of applying this kind of lens to different systems is to just have universal or otherwise early accessible treatment, but even in this, it's can the police access it when they have someone in the back of their car, or do they have to get off their shifts and they don't want to fill in their paperwork, right, and so how quickly can we get someone into treatment? Co-responder teams, mobile crisis teams, these are kind of all of these model programs, and some do need more data, but just again, to kind of think about how we would consider and frame this as an example, and then thirdly, tertiary prevention, how could we reduce carceral harms for people that are incarcerated behind bars, so we were gonna want to limit, again, from a psychiatric perspective, mental health perspective, according to these values, and what are the costs, right, so length of time behind bars, repeat crimes to go back again, and the specific negative impacts, so some of these features are according to the sequential intercept model again, but you're gonna make kind of court interventions, make correctional psychiatry, more, I guess, along the lines of what the Constitution guarantees in Estella versus Gardner, is that we have care at or above the level of community, which is constitutionally required, reentry planning, community treatment, and specialized supervision, so these are kind of all, you're changing, you're focusing on the values, and you are changing, right, like considering different costs, how we can reduce those costs, increase the values, but again, keeping in mind the different scopes, because if we were just thinking about an individual patient, I don't think, A, any of us would be at a talk like this, right, but we are thinking about them in terms of families, in terms of communities, in terms of systems overall. So in, I just used, I don't think anyone necessarily came to this talk just to hear about criminal justice system, right, this is about value, and balancing cost and quality, but within our book, this is just one chapter that talks about ways to do that, so some other examples within the book that other authors wrote on are just the ones I have listed, but a lot more as well, climate change, end-of-life care, and having a healthy workplace, and so as psychiatrists in this role and in this mode, it's about education, supporting programming that considers these values, costs, and the scope, and specifically, again, for incarceration, just thinking about different financing models as was covered over before, research and advocacy, and all the time, I work with, well, PA students, but a lot of residents and fellows in psychiatry, and people always feel limited in their time to what they can do, but to be an advocate, you can change that scope just as like what we're talking about for considering systems. You can be an advocate in a way within the room with someone, but whatever your skill and time set is already oriented toward, you can be an advocate in that context, and so those are just some of the examples of that, and I think we are on to discussion. Okay, cool. Thank you. So thank you. Thank you to my colleagues. Thank you all for coming at 8 a.m. on a Monday. I appreciate it, and I wanted to open up the floor for questions. I know we presented a lot of material, so we can start with questions. If you have a question, I've been asked to have you please come to the mic. The session is being recorded, so we wanna be able to hear your question. Hi, good morning. Good morning. So sometimes when I see that quadruple aim, it seems to me like a no-brainer, like everyone wins. Patients get better. Insurance companies save money. Why wouldn't we do this? And the question is gonna be like, are the incentives really aligned? Let me give you some examples. Medicaid for a while didn't cover nicotine patches in my state, and I'm like, why would you not? That makes no sense to me. You're gonna save money down the road. These people aren't gonna get cancer and these expensive treatments, and the reason is they will likely not be covering some of these patients later in life, so the incentive in that moment was don't pay for it. So much of what we deal with in psychiatry and society, we have many systems are involved, but it's not one big closed system. For example, they don't wanna pay for injectable anti-psychotics, which would clearly keep people out of the hospital or out of jail because they're not the ones that get that financial hit ultimately. So if we're doing things that keep people out of criminal justice systems and that costs our society a lot of money, the bottom line is the bottom line. Insurance doesn't have to pay for somebody going to jail. So I just wonder how many of those systems are actually at play because it seems like everyone would wanna do this. And even just something even if within healthcare, like if I reduce someone's polypharmacy, I'm saving the Medicaid budget a ton, and yet I never see that. I never see the benefit in my outpatient clinic. So how do we reconcile all this? It seems to make so much sense, when you really get down to it, there's resistance for these very simple reasons. Like people that pay the money don't see the cost savings. Thanks, Karen. Excellent question, excellent points that you've made. Does anyone want to address any of these topics? This doesn't look like it comes out. Is this on? Okay. Yeah, you just kind of point out some of the difficulties that are clear in our systems. That we're really focused, because the system is profit-driven, we're often focused on short-term goals, like get them out of the hospital or get them out of our system so that we don't have to pay for them. That is obviously something that's counterproductive. And we have so many paradoxes within the system like that, that our incentives are misaligned. And because of the fragmentation in the system, we have just a lot of waste and we have systems that don't really focus on health. And that's one of the primary difficulties that we face. How do we get systems to think about health? How do we get systems to think about prevention? In the old days, you used to have these catchment areas. And they're kind of two sides of the coin, right? When you just kind of pay a lump sum and have somebody provide all the care for people within that system, they can really think of longer-term outcomes. But the downside is, and the reason that we moved away from that was because there was poor accountability. So one of the things that is really critical is to figure out the right balance in those things, right? How do we have both accountability and attention to longer-term goals and doing the things at the outset that will really prevent illness rather than just reacting to it? I will just add that I think to your very point, we're still ways away from achieving the goal that you talked about. But I do think there is more of a recognition that treatment on its own cannot be separated from other aspects of people's lives, and that there's a need to pay for upstream interventions. I think that's beginning to kind of percolate. So you see more and more insurance companies are tending to things like what we call social determinants. It's not where the, it's not getting it precisely at what you're talking about, which is almost like a single source payment for all services with accountability built in. We're not there yet, and I think it will be a while before we get there. But there are glimmers of hope that that idea is beginning to come through. Thanks for your presentations. I'm Mike Franz from Bend, Oregon. I'm a practicing child and adolescent psychiatrist. On Fridays, I do the collaborative care model and eat consults for the two largest pediatric primary care clinics in Central Oregon, and I see patients directly at the community mental health program on Friday afternoons, IDD patients in particular, because we found a need for that. But Monday through Thursday, I'm the senior medical director of behavioral health at Regence Blue Cross Blue Shield. It's kind of a larger commercial Medicare Advantage plan in the Pacific Northwest, and it's in that role primarily that I'm gonna ask you some questions. So I'm very interested in figuring out sustainable reimbursement for integrated behavioral health in medical settings, starting with primary care, but especially medical outpatient as well as hospital settings. And one of the challenges that I found in trying to do that is that we have this fractured, it's a common theme today, multi-payer environment where maybe my health plans membership might compose 10%, 15% at best of any of those health delivery systems. Sure, Medicaid might be 25%, standard Medicare a certain amount, but multiple commercial payers at play such that it's hard to hit a threshold at which the health delivery system would wanna change the workflows, hire the staffing, hit the metrics that we need to decide on to generate alternative payment methodologies that actually cover the costs and incentivize in the right way to allow for the sustainable reimbursement of those novel clinical models like primary care, behavioral health, and collaborative care, which isn't always covered by those Medicare fee-for-service codes. So my thought is that there may be an opportunity in really developing payer-provider collaboratives where we bring the various payers together with our providers and without hitting antitrust issues like we just won't talk rates or reimbursement dollars specifically, agree on the clinical models that we want to support and identify the gated metrics for initial payment followed by a sustainable APM that is gonna cover those costs when outcomes that we all collectively decide on are hit. So in Philadelphia, do you have payer-provider collaboratives that do this in an effort to try to figure out how can we get everybody on the same page rowing in the same direction to build the system we want? Because in the absence of a single payer environment, I think it's challenging to do that. Thank you, that's an excellent question. The short answer is that no, we don't have the, we don't have the arrangement you described. Much of the work of the public health departments and the public mental health system is within Medicaid because about half of Philadelphians actually are eligible for Medicaid. So within that space, there is an increasing push towards, there's been P4P for many years. There's an increasing push towards other value-based reimbursement models, particularly at the outpatient, partial hospitalization levels of care, but not the single, not the sort of level of engagement with commercial payers that you talk about. One of the, and I'd love to hear your thoughts about this. One of the, I suppose, factors that would make such an arrangement workable would be the willingness of the payers to, and the providers, I imagine, to accept downside risk. That is, the willingness to not be paid or even reimburse funds if the outcomes are not as hoped for. I don't know whether that's coming up in any conversation that you're in. It hasn't for the scenario I described, reimbursement in primary care for integration in behavioral health, but it has in this brave new virtual world of specialty behavioral health. And there are definitely players out there that we now have contracts with where were the rate-limiting step. They would have moved to, some of them, full 100% downside risk because they're so bullish on their clinical model that if they're giving a cohort to manage, that they'll decrease the total cost of care. These are often specially virtual substance use disorder providers who know that they can move the dial. And ultimately, that's what we wouldn't do, right? Because they're gonna say, we will save those emergency department visits, those med surge visits for the pancreatitis or the overdose on fentanyl or whatever because we all know 80% of the savings by investing in behavioral health is gonna be born on reducing medical surgical costs, not behavioral health costs. There are such entities that'll say, you don't pay me any fees unless I decrease your total cost of care for this cohort. But if I do, then I get a certain percent of that decrease in total cost of care. So I'm looking forward to that. We're the rate-limiting step because we're still on a fee-for-service contract because it's a struggle to operationalize those APMs, but hopefully we can get there. One of the things that I think that we talk about a little bit in the book is how we get everybody on the same page and how we unify, how we think about assessment and what kind of services are needed. So the LOCUS, Level of Care Utilization System is something that was developed by the AACP to do just that. And I think Oregon has some legislation related to that going on now. And so that's one way to get everybody at least on the same page and talking the same language. This is a bit of a follow-up to actually the first two. I work for a national startup, for-profit, the value-based care for kidney care, and I'm bringing in the behavioral health component to it. And so they are taking the downside risk. And where my sort of ethical elements of this is, they are also taking the upside risk where they expect, because I actually think in the first couple of years it's gonna be fairly easy to play if we do it, a fair amount of profit on the pop-in. And that's where I sort of get stuck a little bit ethically because I think what we're doing is right. I think it's right for the patients. I think it's right for the potential of the outcome of the system of less direct cost. But still, we have that system that you talk about, profit, through this organization. Otherwise, people wouldn't be investing the money that they're putting into it, which is a loss. So, and then I've also worked in the public sector where I've seen money go out the door in totally different ways. I mean, I don't know how I'm asking the question except for presenting the problem that I'm sort of struggling both ethically in our system, how we get stuck in the middle, providing, trying to provide better care, but the advantage of that better care, yes, I get paid pretty well, very well, but not exceptionally. But the exceptional money is going to other people, but those people are also putting a lot of money up and might lose it. You know, and it's just a profit system. Yeah, no, thank you for your comment. If you haven't already, have you guys read the article, Salve Lucrum, The Existential Threat of Greed in the Healthcare System? If you haven't already, I highly recommend it. It's from February 2023, this year, by Don Berwick. And, you know, I like to say it's not healthcare that we have, it's sick care, right? We have a revolving door that promotes people coming in constantly and you pay for those services. And it's not a system, right? A system implies collaboration and connection. So, healthcare, sick care, our paradigm is primed for a shift and a change. And I like to leave with something positive. You know, we have a lot that needs to be improved, but there are some good elements and we want to make sure that we emphasize those. I had asked, you know, a patient of mine mentioned that I was giving this talk and, you know, what is the value of psychiatry? And she said, the connection, doc. Don't you get it? She's like, this is why I come in. And I, you know, and I'm thinking to myself, 15, 20 minutes, like what value could I possibly be providing? But I hope a takeaway is, at the end of the day, to be able to connect with people at a human level, despite the system's difficulties is important to keep in mind. At least, that's what gets me up in the morning some days. So, thank you all for coming. Thank you all for putting up with my cough. I appreciate it. And any other questions, we'll be here. Thank you.

psychiatric care

cost and quality

value-based insurance

socio-political determinants

innovative financing

preventative care

criminal justice system

alternative payment models

healthcare inefficiencies

systemic changes

personal connections

patient needs