A Healthy Mind for a Healthy Population
The U.S. health care system must pay more attention to providing quality care to people with mental problems or substance-use conditions.
Each year, more than 33 million U.S. residents receive health care for mental problems and/or for conditions resulting from the use of alcohol, illegal drugs, or prescription medications. The total comprises approximately 20% of working-age adults, a nearly identical portion of adolescents, and 6% of children. Millions more people need care but for various reasons do not receive treatment. For example, although more than 3 million people aged 12 or older received treatment in 2003 for alcohol or drug use, more than six times that number—9% of this age group—reported abusing or being physiologically dependent on alcohol, illicit drugs, prescription drugs, or a combination of these.
Mental problems and substance-use conditions (M/SU conditions, for the sake of convenience) frequently occur together. They also accompany a wide variety of general medical conditions, such as heart disease, cancer, and diabetes, and thereby increase risk of death. For example, approximately one in five patients hospitalized for a heart attack suffers from major depression, and such patients are roughly three times more likely to die from their heart problems than are patients without depression.
Even among people who receive treatment for their M/SU conditions, many often get care that is contrary to what science has shown to be appropriate. Clinicians’ departures from evidence-based practice guidelines have been documented for conditions as varied as attention-deficit hyperactivity disorder, anxiety disorders, conduct disorders in children, depression in adults and children, opioid dependence, use of illicit drugs, comorbid mental and substance-use illnesses, and schizophrenia. These deviations from standards of care can result in significant harm to patients.
Collectively, M/SU conditions rank as the nation’s leading cause of combined disability and death among women and the second highest among men. The conditions also impose great costs on the economy through increased workplace absenteeism, “presenteeism”(attending work with symptoms that impair performance), days of disability, and significant work failures and accidents. Among children, the conditions adversely affect educational achievement. In sum, M/SU conditions make large and costly demands on the nation.
Clearly, the United States has failed to recognize the magnitude of M/SU conditions and to deliver adequate health care to people in need. To help remedy matters, the Institute of Medicine in early 2006 issued a report detailing the distinctive features of mental and substance-use health care and offering a comprehensive agenda for improving such care.
The report builds on a previous pioneering IOM report, Crossing the Quality Chasm: A New Health System for the 21st Century, issued in 2001, that reviewed the nation’s general health care system, chronicled its shortcomings, and called for its fundamental redesign. The new report, Improving the Quality of Health Care for Mental and Substance-Use Conditions, finds that its predecessor’s conclusions are equally true for M/SU health care. Overall, the system often is ineffective, untimely, inefficient, inequitable, and not patient-centered. At times, it is even unsafe. As is true of general health care, M/SU health care requires fundamental redesign.
In redesigning the system, the guiding principle must be that mental illnesses, substance-use illnesses, and general illnesses are highly interrelated, especially with respect to chronic illness and injury. Improving care delivery and health outcomes for any one of the three depends on improving care delivery and outcomes for the others. A corollary principle is that health care for general, mental, and substance-use problems and illnesses must be delivered with an understanding of the inherent interactions between the mind/brain and the rest of the body.
Redesigning the health care system that tends to people with M/SU conditions will require concerted actions by a host of parties. Among the parties to be involved and the actions needed are the following:
Individual clinicians. Clinicians treating patients with M/SU conditions should support their decisionmaking abilities, as well as their preferences for treatment and recovery. In today’s climate, misinformation and stigma lead many clinicians to underestimate their patients’ abilities to make decisions, to help in planning their treatment, and to carry out a plan for recovery. Such underestimation effectively undermines a patient’s “self-efficacy”: the belief that he or she is capable of carrying out a course of action to reach a desired goal. Promoting self-efficacy is key for many patients, as these beliefs are excellent predictors of how well an individual will perform the day-to-day actions necessary to successfully manage and live with M/SU conditions such as depression, bipolar illness, and alcohol dependence, as well as illnesses such as diabetes, asthma, and HIV. Self-management activities include, for example, monitoring illness symptoms; using medications appropriately; practicing behaviors conducive to good health in such areas as nutrition, sleep, and exercise; employing stress reduction practices; communicating effectively with health care providers; and practicing health-related problem solving and decisionmaking.
Clinicians can support their patients’ decisionmaking abilities and preferences in a number of ways. These approaches include incorporating informed patient-centered decisionmaking throughout their practices (including active patient participation in the design and revision of treatment and recovery plans), and supporting informed family decisionmaking when children are being treated. Clinicians also can establish and maintain formal linkages with community resources to support patient illness self-management and recovery—an important step, because an increasing amount of M/SU health care is taking place within community settings.
Clinicians should avoid coercing patients into treatment whenever possible. Such restraint has taken added meaning as new mechanisms for pressuring or compelling individuals to undergo treatment have evolved, including coercion from the criminal justice and welfare systems, schools, and workplaces. When coercion is necessary and legally authorized, clinicians should make sure that the care they provide is patient-centered. In such cases, clinicians should ensure that patients and their caregivers understand the policies and practices used for determining dangerousness and decisionmaking capacity; use the best available comparative information on safety, effectiveness, and availability of care and providers to guide treatment decisions; and maximize patient decisionmaking and involvement in the selection of treatments and providers.
Among other actions, clinicians should conduct age-appropriate screening of their patients for comorbid mental, substance-use, and general medical problems. They should increase their use of valid and reliable patient questionnaires or other patient-assessment instruments to systematically assess progress and outcomes of treatment, and then use these measures to continuously improve the quality of the care provided. They should routinely share (with the patient’s knowledge and consent) information on patients’ problems and pharmacologic and nonpharmacologic treatments with other providers treating the patients. They should establish clinically effective linkages with other providers of mental health and substance-use treatment for care coordination, and they should coordinate their services with those of other human-services and education agencies.
On a broader level, clinicians should become involved in committees and initiatives working to promote and develop the National Health Information Infrastructure. This is a public-private effort now under way to improve health care providers’ ability to obtain information quickly on a patient’s health and health care and to share this information in a timely manner with other providers caring for the patient. The system will encompass electronic health record systems with decision support for clinicians, a secure platform for exchanging patient information across health care settings, and data standards that will make shared information understandable to all users.
Health care delivery organizations. In general, organizations should carry out the same practices as recommended for individual clinicians. This includes supporting their patients’ decisionmaking abilities and self-efficacy beliefs, and developing formal policies that will foster the involvement of patients and their families in the design, administration, and delivery of treatment and recovery services. Such direct contact with individuals with M/SU diagnoses in a collegial, equal-status setting is one of the most powerful tools for reducing stigma and discrimination. Organizations also need to develop formal policies that will ensure patient protection in cases where care has been coerced.
Among other actions that mirror recommendations for individual clinicians, organizations should screen their patients for comorbid mental, substance-use, and general medical problems. This is especially important for providers of services to high-risk populations; such providers include child welfare agencies, criminal and juvenile justice agencies, and long-term care facilities for older adults. Organizations also should establish formal linkages internally and with other providers of M/SU treatment, in order to ensure that patients have ready access to a seamless web of care. It will not be sufficient merely to make referrals to other providers or to establish ad hoc informal arrangements.
In addition, organizations should increase their use of patient questionnaires or other reliable patient-assessment instruments to assess the progress and outcomes of the treatment they provide. Patients are increasingly recognized as valid judges of the quality of their health care. They not only can provide direct feedback as to the effectiveness of treatment. They also can report on their experiences with care delivery processes, such as the extent to which they were able to participate in decisions about their own care and to gain skill in the self-management of their illness. Physicians and organizations in general health care already are using patient questionnaires to measure treatment outcomes. For example, the VF-14 questionnaire on eyesight asks patients about the amount of difficulty they experience in pursuing usual daily activities, such as driving and reading fine print. Many insurers require that the results of the VF-14 be used and reported as part of claims payment. Such consumer surveys may be an even more appropriate and valuable source of data on the outcomes of M/SU health care. Although laboratory tests or other physical measures, such as blood glucose levels or blood pressure, can measure outcomes of general health care accurately and easily, fewer laboratory or other physical examination findings can measure whether mental illness or drug dependence is remitting. Thus, patients are likely to be the best source of information on the extent to which their symptoms are abating and functioning is improved.
Organizational leaders also should get involved in efforts to develop health care data and information technology standards as part of the National Health Information Infrastructure, and they should encourage their staff members to get involved as well.
Health plans and purchasers. Health plans and group purchasers of treatment services, which help shape the environment in which M/SU health care is delivered, can create powerful incentives for improving quality. They can underpin efforts by clinicians and organizations to support patient self-efficacy, illness self-management, and patient recovery by paying for programs that meet evidence-based standards. Plans and purchasers should use M/SU health care quality measures in their procurement and accountability processes; provide consumers with comparative information on the quality of care provided by practitioners and organizations; and adjust their copayments, service exclusions, benefit limits, and other coverage policies in order to remove any barriers to or restrictions on effective and appropriate treatments.
Plans and purchasers also should participate in consortiums that promulgate quality measures for providers, organizations, and systems of care, and that advocate for a common, continuously improving set of M/SU health care quality measures. These measures should be understandable by multiple audiences, including consumers, group purchasers of health care, and quality-oversight organizations. Plans and purchasers should continually review the measures’ effectiveness in improving M/SU care.
In addition, purchasers should encourage the widespread adoption of information technology for M/SU care. They can do this in a number of ways. They can offer financial incentives to individual clinicians and organizations for investments in technology needed to participate fully in the emerging National Health Information Infrastructure. They can provide capital and other incentives for the development of virtual networks to give individual clinicians and small-group providers standard access to software, clinical and population data and health records, and billing and clinical decision-support systems. They can provide financial support for continuing technical assistance, training, and information technology maintenance. And as part of their purchasing decisions, they can include an assessment of how extensively clinicians and health care organizations use information technology for clinical decision support, electronic health records, and other quality-improvement applications.
Purchasers that offer a choice of health plans should find ways to reduce health plans’ incentives to limit the coverage or quality of M/SU care in order to avoid enrolling individuals with costly illnesses. Similarly, state governments should revise their procurement processes to give the greatest weight to quality of care. One promising way of doing this is to assign relatively low weight to a bid’s price-related dimensions and relatively higher weight to features that address quality of care. A second approach is to adopt a rate-finding process that sets a price for bids and then focuses the competition on the quality and service dimensions of performance. State and local governments also should reduce their emphasis on the grant-based systems of financing that currently dominate public M/SU treatment systems, while increasing the use of funding mechanisms that link some funds to measures of quality.
National associations of purchasers should decrease the burden of variable reporting and billing requirements by standardizing requirements at the national, state, and local levels.
State policymakers. State policymakers can facilitate improvements to quality by attending to the laws, regulations, and administrative practices that pertain to the confidentiality of patient information and to coerced treatment. They can do this by coordinating policy across governmental units responsible for general medical care and M/SU health care, as well as across the human services agencies with which these units interact. As one particular step, state governments should revise policies that create inappropriate barriers to the communication of information among M/SU health care providers and among these providers and general health care providers.
In their roles as purchasers, state governments should encourage the widespread adoption of electronic health records, computer-based clinical decision-support systems, computerized provider order entry, and other forms of information technology for M/SU care by taking the actions listed above for health plans and purchasers. State legislatures also should improve coverage for M/SU treatment by enacting a form of benefit standardization known as parity, which equalizes the benefits coverage of mental and substance use illnesses with the benefits provided for general medical illnesses.
Federal policymakers. Building the necessary infrastructure for quality improvement requires federal leadership. The Department of Health and Human Services (DHHS) must strengthen and coordinate the synthesis and dissemination of evidence on effective treatments and services that now takes place through multiple uncoordinated initiatives. This effort will lead to better use of scarce resources and help to alleviate some of the current confusion about what constitutes “evidence-based” care.
Toward this aim, DHHS should charge one or more entities with an interrelated set of tasks. One task would be to define, describe, and categorize current screening, preventive, diagnostic, and therapeutic M/SU interventions and develop electronic “codes” for each so they can be captured in routinely used data sets approved under the Health Insurance Portability and Accountability Act. A second task would be to rate the strength of the evidence on the efficacy and effectiveness of these interventions, categorize them accordingly, and recommend or endorse guidelines for their use. Armed with this information, the ultimate task would be to expand and strengthen efforts to disseminate proven evidence-based practices.
In these activities, the designated group or groups should work with the Centers for Disease Control and Prevention, the Agency for Healthcare Research and Quality, and other opinion leaders and sources of expertise looked to in general health care. Involving general health care opinion leaders is particularly important, because the majority of consumers initially turn to their primary care providers for mental health services. Primary care physicians and physician specialists other than psychiatrists also prescribe the majority of psychotropic medications.
Given current federal fiscal constraints, DHHS likely will need to call on public- and private-sector structures and processes already in place to carry out these activities. However, the department will need to provide them with formal support and resources to enable and sustain their activities.
Among other jobs, the government should reexamine laws, regulations, and administrative practices that create barriers to sharing substance-use treatment information with mental and general health care providers also treating the patient. As a purchaser, the government should require all health care organizations with which it contracts to ensure appropriate sharing of clinical information essential for coordination of care with other providers treating their patients.
The government should encourage the adoption of electronic health records, computer-based clinical decision-support systems, computerized provider order entry, and other forms of information technology for M/SU care. This can be done by pursuing the same actions prescribed for all purchasers. In a complementary effort, DHHS should create and support a continuing mechanism to engage health care stakeholders in the public and private sectors in developing consensus-based recommendations to address unique aspects of information management related to M/SU health care. The department should then provide the recommendations to the standards-setting groups working with the Office of the National Coordinator of Health Information Technology.
Such actions are sorely needed, because the M/SU health care system lags far behind the general health care system in the use of information technology. For example, interviews conducted in 2003 with the directors of 175 substance-use treatment programs nationwide revealed that approximately 20% of the programs had no information services, e-mail, or even voice mail for their phone systems. Fifty percent had some form of computerized administrative information system for billing or administrative record-keeping, but these were typically available only to administrative staff. Thirty percent of the programs—mostly those that were part of a larger hospital or health systems—had seemingly well-developed information systems. But only three programs had an integrated clinical information system for use by the majority of their treatment staff. Psychiatrists as a group also are known to have lower rates of information technology support for patient care as compared with all physicians.
The government must act as well to ensure that the emerging National Health Information Infrastructure has adequate resources to address M/SU health care. Here again, the statistics are grim. In 2004, the government awarded $139 million in grants and contracts to promote the use of health information technology. But of the 103 grants awarded, only one specifically targeted M/SU health care. Thus, the government must take steps to direct more grants and contracts for the development of components of the National Health Information Infrastructure that relate to M/SU health care.
The government also has a key role to play in improving the quality of M/SU health care. The DHHS must provide leadership, strategic development support, and additional funding for research and demonstrations to establish the efficacy of various treatment methods as they become available. This initiative should coordinate the existing quality-improvement research efforts of the National Institute of Mental Health, National Institute on Drug Abuse, National Institute on Alcohol Abuse and Alcoholism, Department of Veterans Affairs, Substance Abuse and Mental Health Services Administration, Agency for Healthcare Research and Quality, and Centers for Medicare and Medicaid Services. It also should develop and fund cross-agency efforts in necessary new research. To that end, the initiative should address the full range of research needed to reduce gaps in knowledge at the clinical, services, systems, and policy levels and should establish links to and encourage expanded efforts by foundations, states, and other nonfederal organizations.
In addition, the government must act to help beef up the M/SU workforce. Although the diagnosis and treatment of general health conditions are typically limited to physicians, advanced practice nurses, and physician assistants, M/SU health care clinicians include psychologists, psychiatrists, other specialty or primary care physicians, social workers, psychiatric nurses, marriage and family therapists, addiction therapists, psychosocial rehabilitation therapists, sociologists, and a variety of counselors, including school counselors, pastoral counselors, guidance counselors, and drug and alcohol counselors. Congress should authorize and appropriate funds to create and maintain a Council on the Mental and Substance-Use Health Care Workforce. As a public-private partnership modeled on the Council for Graduate Medical Education and the National Advisory Council for Nurse Education and Practice, the council would develop and implement a comprehensive plan for strengthening the quality and capacity of the workforce to improve the quality of M/SU services. The government also should support the development of M/SU faculty leaders in health professions schools, such as schools of nursing and medicine, and in schools and programs that educate M/SU professionals, such as psychologists and social workers.
Accreditors of health care delivery organizations. By their very definition, accreditation groups can create incentives for M/SU health care organizations to make needed improvements. In particular, accreditors should adopt standards that mesh with the above recommended policies and practices. For example, accreditors should require that organizations have in place policies that encourage informed, patient-centered participation and decisionmaking throughout their care, including treatment, illness self-management, and recovery plans. Moreover, accreditors should incorporate into their standards any competencies or requirements established by the proposed Council on the Mental and Substance-Use Health Care Workforce.
Institutions of higher learning. To better prepare the workforce to function in a work environment that more aggressively pursues quality improvement, institutions of higher education should place much greater emphasis on interdisciplinary learning and should bring together faculty and trainees from their various education programs. They also should facilitate and assist the work of the Council on the Mental and Substance Use Health Care Workforce.
Funders of research. Public and private sponsors of research on M/SU and general health care should focus on several priority areas. For example, they should support the development of reliable screening, diagnostic, and monitoring instruments that can validly assess response to treatment. These instruments should include a set of M/SU “vital signs” comprising a brief set of age- and culturally appropriate indicators for monitoring patient symptoms and functional status. The indicators must be suitable for use in screening and early identification of problems and illnesses and for repeated administration during and after treatment. Funders also should support the development of strategies to reduce the administrative burden of implementing quality-monitoring systems, as well as the development and refinement of methods for providing information to the public on the effectiveness of a range of interventions.
In addition, funders should devise health services research strategies and innovative approaches that address treatment effectiveness and quality improvement in usual settings of care delivery. To that end, they should develop new research and demonstration models that encourage local innovation and create a critical mass of partnerships involving researchers and stakeholders. Stakeholders should include patients, parents or guardians of children, clinicians, organization managers, purchasers, and policymakers.
Finally, DHHS, in collaboration with other government agencies, states, philanthropic organizations, and professional associations, should create or charge one or more entities as national or regional quality-improvement resources. They would test quality-improvement practices, disseminate knowledge about the practices, and provide technical assistance and leadership across public- and private-sector M/SU health care settings.
Across every sector of society, evidence of the effects of mental and substance-use problems and illnesses on each other and on general health continues to accumulate. But there is a way forward that promises to reduce the toll.
To gain the fullest measure of success, participants in every sector of the health care system must commit to action. That is the hope. Still, success need not be an all-or-nothing proposition. Individual clinicians and organizations acting alone can bring about significant improvements in the quality of care they provide to the people they serve. It would be a start—and it might point the way to even greater rewards as their counterparts gradually join in.