Geoffrey M. Orokos

Like anyone who owns a computer, tablet or smart phone, I am frequently reminded during the budget and sequester discussions that the muscle driving our social insurance programs – our nation’s economic prosperity – is fatigued. With our budget deficit forecasted in 2013 at $845 billion, total debt more than $16.1 trillion, poverty at 15.1 percent and total health care spending near 18 percent GDP – many agree that cause for concern is warranted.

As a mental health case coordinator living and working in New York State’s poorest city-per-capita – I find these talks and statistics particularly unnerving – as one in three Americans receiving Medicare today receive treatment for a cognitive or mental impairment. On my own caseload, more than half of my clients are Medicare recipients.

However, it was refreshing to learn at the National Academy of Social Insurance’s 25th annual conference, Medicare and Social Security in a Time of Budget Austerity, social insurance experts are considering these fiscal challenges. It was also gratifying to leave with the belief that there’s a pragmatic solution Medicare can use to lower health care costs system-wide.

Synthesizing “Micro” and “Macro” changes for Medicare to lead the way
As explained by David Blumenthal of The Commonwealth Fund in his conference presentation, “We Already Know How to Fix Our Health Care System, So Why Can't We?” –“micro” and “macro” systems need to be addressed to lower our nation’s spending on health care costs. A micro system includes people, processes and practices that deliver a health care service. A macro system is the legal, institutional and organizational framework outlining health care services.  Both are dependent on the other to achieve effective and efficient health care outcomes. And, the Patient Protection and Affordable Care Act (ACA) in 2010 ultimately set the precedent in our era for health care macro reform.

Although the ACA doesn’t provide the macro reform of a single-payer system through Medicare, as some countries have used to curb health care costs, it initiated the necessary framework for implementing the micro health care delivery methods in these single-payer systems. As described at the NASI conference by President of the Medicare Rights Center Joe Baker, Medicare can therefore continue to be a leader of reduced health care spending, an innovator for payment and delivery system reforms advanced by the ACA and a solution to the rising health care costs system-wide.

For example, the ACA provides provisions that allow Medicare to encourage the use of primary care providers (PCPs) to deliver preventative and timely medical care – which reduce costs and improve outcomes.  Such provisions include bonuses to PCP healthcare providers, increased rates for PCPs and funding for training the PCP workforce. Additionally, the ACA also provides provisions that allow Medicare to embrace the Mental Health Parity and Addiction Equity Act of 2008 – or, equal payments for mental health (MH), substance use and medical services – to reduce costs and improve outcomes. These provisions include incentives to coordinate medical and MH services, enhance community-based service options for MH conditions and reform delivery-systems to address traditional system fragmentation.

Consequently, like single-payer systems, integrating MH and primary care services for Medicare recipients presents a viable solution to reducing health care costs system-wide. Especially when considering the data and facts:  

  • About one-third of all Medicare beneficiaries have been diagnosed with a cognitive or mental impairment.
  • Nearly 6.5 million Americans – or 18 percent – aged 65 and older suffer from depression.
  • Those with chronic conditions such as cancer, diabetes and heart disease are 2-5 times more expensive to treat if they also have depression.
  • An estimated 70 percent of primary care visits have a psychological component to the visit – such as smoking, a sedentary lifestyle, non-adherence, substance abuse and obesity.

Furthermore, of the countries that underscore PCP use with significantly less GDP spending on health care – integrated behavioral health care in primary care settings are amply employed:

  • Australia, which spends roughly 8.7 percent GDP on health care costs, has focused on integrated care models for serving their elderly population, with PCPs linked to community psychologists and psychiatrists.
  • The United Kingdom, which spends approximately 9.6 percent GDP on health care costs, implements holistic primary care highlighting early identification of co-morbidity, reduced stigma and social inclusion. Mental health concerns are first addressed with the PCP and MH specialist, and then referred to outside services when necessary.

However, in the U.S., employing large-scale integrated services requires additional macro system changes. Current Procedural Terminology code modifications for reimbursing integrated MH specialist consultations could encourage current PCPs to integrate services. Medicare can also reimburse for integrated MH care deliveries and services in PCPs – and vice-versa. Undoubtedly, special interest groups in both the medical and behavioral health field may be hesitant to change. Yet, what reform hasn’t stirred-up opposition?

Essentially, by synthesizing the macro and micro systems necessary for Medicare to first cover integrated primary care services, and then reduce costs and improve outcomes – private insurers can follow suit. And, with reduced health care costs system-wide, the mental health consumers I serve living in New York’s poorest city-per-capita may hopefully have one less barrier in their pursuit to lead meaningful and fulfilling lives.

Geoffrey is a Supported Housing Case Coordinator in the NYS mental health sector with the non-profit organization Fulton Friendship House, Inc. In addition to helping those with serious and persistent mental illnesses locate, secure, and maintain safe and affordable housing – Geoffrey assists in their pursuit of independent living with navigation through the social welfare system. He is also pursuing his Master of Public Administration in Public Policy Analysis at the Rockefeller School of Public Administration & Policy, University at Albany, State University of New York. Geoffrey was one of six students and young professionals awarded a scholarship to attend NASI’s 25th annual policy research conference January 31- February 1, 2013, in Washington, DC.

Posted on: March 28, 2013

One Comment

  1. Dave Baldridge March 29, 2013 at 10:14 pm - Reply

    Rates of depression among
    Rates of depression among American Indians diagnosed with diabetes have been described as up to 28 percent. Yet little, if any, mental health assistance is usually available to them, or to many other Americans suffering from chronic disease. This issue runs far deeper than Procedural Terminology code modifications. The medical community’s failure to deal with psycho-social issues (integrated services seems an innocuous and ineffective euphemism) as critical aspects of chronic disease care remains discouraging and expensive.

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