Mental Health in the Era of COVID-19

By |2020-05-22T20:20:09+00:00May 22nd, 2020|Uncategorized|

Mental Health in the Era of COVID-19

Mental health care is a deeply personal issue for me. My experience in trying to help friends and family navigate the deeply flawed and broken U.S. health care system is a key part of what drives me to work on access and cost issues for patients, and reimbursement issues for providers.

Mental health conditions are much more common than we might think. According to the National Institute of Mental Health:

  • 1 in 25 people in the U.S. – about 11 million people – experience a serious mental illness that significantly limits a major life activity such as working or caring for family members;
  • 1 in 5 people – about 47 million people – experience a mental health condition, for example, ADHD, anxiety, bipolar disorder, or depression, at some point in their lifetime.

But we have not built a system that acknowledges, destigmatizes, or serves patients who experience mental health conditions.

Nearly 10 years ago, Támara Hill, a licensed therapist and certified trauma professional in private practice, wrote A Failed Mental Health System: The Top 5 Failures, which are:

“1) Poor access to financial support/high insurance costs

2) No direction after a psychiatric diagnosis

3) Feeling overlooked, alone, uncertain, and confused

4) Lack of knowledge about the mental health system in general

5) State laws and treatment policies that interfere with appropriate and timely treatment.”

Not much has changed, even with full implementation of the Affordable Care Act. Access to care, in particular, continues to be a problem. Before the coronavirus pandemic, even though most people with any mental illness under age 65 had some sort of health insurance, less than 10% had received any kind of inpatient treatment. For the 1 in 5 people experiencing a mental health condition (not considered a serious mental illness), less than 30% received outpatient mental health treatment, according to the Kaiser Family Foundation.

The Mental Health Consequences of COVID-19

The mental health consequences of COVID-19 are widespread and affect nearly everyone. Of course, they don’t affect everyone equally or in the same way. Further, we don’t really know the extent of what people are experiencing and what mental health care needs people will have in the future.

From a systems point of view, it seems obvious to say, but we need to make changes immediately to boost access to services and treatment, including destigmatizing the need for care, lowering costs and other barriers to patients, and improving reimbursement for all types of providers who can provide mental health care. Telehealth might be a great place to start!

Systemic changes also need to consider how communities can support mental health care, not just how large hospitals or integrated provider groups can provide medical treatments. Dr. Sandro Galea, Dean of the Boston University School of Public Health, made several suggestions recently in a co-authored piece focused on prevention and early intervention approaches to address mental health needs during and after the coronavirus pandemic, including offering stepped care, “training nontraditional groups to provide psychological first aid, and helping teach the lay public to check in with one another and provide support.”

Love, Care, and Concern

From a personal perspective, we might consider whether there is some action that can be taken immediately. Most of us are able, at least some of the time, to send a note, make a call, make a donation, or simply act compassionately toward another human in our path. Offering love, care, and concern will not fix all of the systemic problems of mental health care payment and delivery in the U.S. I am committed to continue working on these issues in my role as a policy advisor.

But in the meantime, I am also committed to continue to offer love, care and support to others. If you can, please join me.

Note: For useful information and resources related to Mental Health and COVID-19, please see:

Mental Health America

Mental Health Coalition

There’s No Clarity Forthcoming

By |2020-05-14T17:50:13+00:00May 14th, 2020|Uncategorized|

There’s No Clarity Forthcoming

We analyze state COVID19-related orders and materials every day for clients.

We were asked recently if we thought there would be a checklist large, national non-retail businesses could follow to ensure the health and safety of their workers.

Our response was quick: there is no clarity forthcoming. You will need to make your own plan.

There are quite a few frameworks, roadmaps, plans and guidelines being published by states and other government entities, even if some are not official. Two of the most detailed, thoughtful and useful are Utah Leads Together and the Washington’s “New Normal” planning documents, in my opinion.

One big problem, however, is all of the guidelines say something different.

Today, the Information Technology Industry Council, which represents some of the biggest employers in the U.S., wrote a letter asking for governments to “coalesce around a single set of guidelines that are comprehensive, reduce the risk of a patchwork response, and make it easier for all employers to identify and follow health-protective guidance specific to COVID-19.”

In this case, #BigWillNotWin. There is no coordination or coalescing or clarity forthcoming. What’s your plan?

Big Will Win, If We Let It

By |2020-05-13T21:31:41+00:00May 13th, 2020|Uncategorized|

Big Will Win, If We Let It

As the coronavirus pandemic unfolds, so far it appears #BigWillWin in health care (in other areas too, but we focus on health policy at M2!).

For example, spending on primary care in the U.S. is comparatively low, accounting for 5 to 7% of total U.S. spending, and primary care practitioners are among the lowest paid specialties. The combination of already low payment and patients’ inability to use telehealth as a substitute for face-to-face visits has meant nearly half of primary care practices in an April survey said they are experiencing “financial strains threatening practice closures.”

But Walmart Health is expanding, as “physician practices face cash crunch.” Teladoc saw a 50% week over week coronavirus surge in March, even though it already provides access to 50,000+ medical experts for more than 36 million patients.

More broadly, private equity was spending record amounts buying U.S. health care entities even before the pandemic, and 2019 marked the first time “employed physicians outnumber[ed] self-employed physicians.

As a policy matter, #BigWillWin in health care if we let it, but are we thinking enough about whether that’s a good idea?

Telehealth – What Are We Not Thinking Enough About?

By |2020-05-13T15:27:09+00:00May 13th, 2020|Uncategorized|

Telehealth – What Are We Not Thinking Enough About?

In 1962, Elroy Jetson had a telehealth visit from his home.

In 2019, 10% of people in the U.S. had used telehealth at least once. As of April 2020, surveys show 20% of people in the U.S. have had a telehealth visit. Telehealth is definitely having a moment. It isn’t hard to find articles saying the rapid uptake of telehealth because of current coronavirus distancing requirements will cause a lasting shift toward online care. If federal and state regulatory changes stay in place, reimbursement for providers is stable and cost-sharing for patients is reasonable, telehealth may very well be used by more and more people in the coming years.

What Are We Not Thinking Enough About?

1) Systemic inequities make widespread telehealth adoption difficult at best

Athena Cross, in The Technological Divide and Inequities in Health, explains, “as the health care system runs toward technological innovation, it is important not only to note the digital divide, but also the historical injustice in health that may inhibit adoption and participation by our most vulnerable and marginalized communities.”

We like to think that everyone has access to health care, and telehealth means a patient is simply having a video call with their existing health care provider. That isn’t what is happening right now. (Later this week we will write more on how #BigWillWin…)

2) Telehealth works better for some services than others

Childhood vaccine orders are down significantly, and diagnostics used to screen and monitor cancer (such as Pap smears and colonoscopies) have dropped dramatically these past few months, as these services are nearly impossible to deliver virtually. On the other hand, claims data is showing more than 50% of mental health visits were delivered via telehealth in the last week of March.

3) Telehealth today is favoring infrastructure over communities

A core promise of telehealth is improved access. But we are not thinking enough about how communities – not just patients, but also community providers and organizations, may be left behind if large corporations hire contract health practitioners who live hundreds or thousands of miles away to deliver “care” at the press of a button. How might local communities be worse off if there is no health care provider in their area? Or if health care providers don’t have race or ethnicity or culture or language or geography, etc. in common with the patients they are serving?

Will the “solution” of telehealth leave people better off? It seems we need to do significantly more thinking and balancing of priorities before we make massive policy and reimbursement changes to support this modality.

State Health Policy Resources for the COVID-19 Era

By |2020-03-26T17:05:27+00:00March 26th, 2020|Health Care Trends, Medicaid, Medicare, State Health Initiatives, Uncategorized|

State Health Policy Resources for the COVID-19 Era

M2’s focus has always been state health policy, and right now, WOW, there’s a lot of action at the state level! We pulled together a list of resources for anyone wanting to take a closer look at state actions and/or policies by state. See our list below and feel free to share additional state level policy resources you are finding useful.

It’s National Entrepreneurship Week. Here’s how to be an entrepreneur wherever you are.

By |2020-02-21T18:21:49+00:00February 21st, 2020|Uncategorized|

It’s National Entrepreneurship Week. Here’s how to be an entrepreneur wherever you are.

The word entrepreneur may bring a certain definition to mind, but it doesn’t have to. The most obvious definition of an entrepreneur, and the one used by economists for counting purposes, is a person who starts a business venture. This definition is fairly narrow as the chart from The Kauffman Foundation below shows.

Not counted in these numbers, for example, are “sidepreneurs,” those people who are trying out an idea that could be a business while they are otherwise employed. In 2005, I was lucky enough to have an employer that allowed me to start my side idea, and M2 Health Care Consulting was born! Turns out, this is becoming a very popular approach.

According to The American Express 2019 State of Women-Owned Businesses Report, the growth rate of sidepreneurs over the past five years is much higher than entrepreneur growth rates generally (see chart below). Notably, this method seems to be very popular with women, and even more so with women of color. While women generally are starting businesses at higher rates than men, the growth rate of black women entrepreneurs between 2014 and 2019 is 50% compared to 9% of all businesses, and the growth rate of black women sidepreneurs in the same time period is 99% compared to 32% of all businesses.

You can use the entrepreneur mindset anywhere

As a proud entrepreneur, I have learned by both succeeding and failing as a business owner. But the concept of entrepreneurship goes well beyond business. The word, as derived from the French, means a person who organizes and manages a task or set of tasks, usually with considerable initiative and risk.

From this perspective, any chance to oversee a meeting, manage a project or start something new at your organization, is an opportunity to be an entrepreneur. So how do you do it? Here are four tips for facing the risk of failure and increasing the likelihood of success when starting something new.

1. Love uncertainty
When you are asked to lead a new project, one of the hardest parts to manage is the uncertainty. Where do you start? What comes first? Who should be included? How do you make it all work? Use the entrepreneur mindset and love uncertainty. No matter how effective you are at managing and organizing, surprises will happen. A key team member will call in sick. A budget will get slashed. Try to think of uncertainty as something exciting, not scary. A challenge to be met, not a warning sign of failure.

2. Plan thoroughly
I have both sales people and entrepreneurs in my family. From a young age I heard them say, “Plan the work, work the plan.” While I didn’t understand the phrase at first, I felt like someone had taught me a magic trick when I put it to use in real life. The essence of entrepreneurship is organizing and managing. To do both of those things well, it is imperative to create a written plan. With steps. And a timeline! Then use that plan to guide your days, weeks, and months. When you complete a step, take note. Was it completed on time? Did it require sub-tasks? Was it dependent on the step before it? Learn from your plan and your working of the plan. The more thorough you are, the more opportunities you have to learn, improve and succeed.

3. Listen carefully
It is the rare successful project that never interacts with another human. Running a business, a non-profit, or a project all require working with people in one way or another. The better you are at listening carefully to your customers, funders, co-workers, and anyone else with a stake in your success, the more likely it is that the project will succeed. When a customer says the product doesn’t work well, listen carefully. What was their experience? Was it unique? Can you fix it? When a co-worker expresses concern about a deadline for the project you are running, listen carefully. Are they trying to tell you they need more time? Warning you about a pitfall you didn’t anticipate? Try not to take things too personally. Listen carefully and assume other people want to help the project or business succeed, not that they want you to fail.

4. Recover quickly
We all fail at something eventually. But there is a difference between failing and learning. To fail is to stop, but to learn, is to keep going. Take the information or lesson from the failure and recover quickly. Get back up. Try again. Don’t take it too personally. You are not a failure. You had a failure. Use the entrepreneur mindset to see that failure as a learning opportunity. Then recover yourself and get back at it!

An entrepreneur isn’t only a person who starts a new business. It is any person who uses a certain mindset to face the risk of failure head-on. So go ahead, be an entrepreneur wherever you are!

Data, Charts, and Policymaking – Is there a Relationship?

By |2020-01-30T20:16:57+00:00January 30th, 2020|Uncategorized|

Data, Charts, and Policymaking – Is there a Relationship?

In a previous blog, we noted some recent studies with international price comparisons for health care.

Now let’s connect some of that data with the policy possibilities.

First, consider two policy proposals currently under consideration that would address international price differences for pharmaceuticals:

1) Using an International Pricing Index (IPI) in Medicare, “to bring down drug prices and cut down on foreign freeriding” and

2) Allowing states to import pharmaceuticals from other countries (which Colorado, Florida, Maine, and Vermont have now passed laws to pursue).

These policy proposals may seem obvious when you look at just one chart, such as the one on the left below published by the International Federation of Health Plans in December 2019 (posted by the Health Care Cost Institute). However, the 2017 Comparative Price Report of International Variation in Medical and Drug Prices shows U.S. prices for ALL medical services are also almost always higher than in comparison countries (see chart on the right below).

       

Similarly, for the most common reason for a hospital inpatient stay, childbirth, health care prices are higher in the U.S. than elsewhere in the world.

 

 

 

 

 

 

 

 

The data represented in just these few charts show that in practically every instance, health care prices are higher in the U.S. than the rest of the world. So yes, it is possible to create policies that would set U.S. prices based on world prices, not only for drugs, but also for all medical services. But such an approach raises a myriad of operational questions, and of course, raises the core question of whether such a policy would even work.

What do we mean by asking whether the policy would “work?”

If what a patient pays is the issue, importing health care prices from other countries is unlikely to have any meaningful effect.

Using childbirth as an example, a recent study published by Health Affairs shows the mean cost for delivery care in the U.S. remained relatively stable between 2008 and 2015. However, “the average proportion of costs paid by patients went up over time (from 12.3 percent in 2008 to 19.6 percent in 2015).”

Further, the required out-of-pocket spending for maternity care was mostly in the form of a deductible, and the amount of deductible, depending on the type of health insurance, rose by 40-50% over the time period studied, as shown in the chart below.

Comparing U.S. medical prices to international prices is one way to view the problem of health care costs and points to certain policy proposals (for example, cutting administration costs, as we’ve mentioned previously), but it doesn’t directly address the pain of paying that patients are feeling.

Instead, when policymakers examine health care cost proposals, they should define what “works” as something that would actually help patients pay less for the care they need.

Is this the year we finally talk about all health care costs?

By |2020-01-13T18:48:48+00:00January 13th, 2020|Health care spending, Health Care Trends, Out-of-pocket spending, Providers, Uncategorized|

Is this the year we finally talk about all health care costs?

While patients, families and employers have been talking about rising (and in many cases, unmanageable) health care costs for years, it appears researchers finally may be getting on board with the issue as well.

Three notable reports came out in the past few weeks comparing what the U.S. spends on health care to other countries.

The U.S. System Costs More to Administer than Other Countries

The Annals of Internal Medicine published a study on January 7, putting new numbers to an old question. How much does the U.S. spend on the administration of health care? About four times more than Canada spends, evidently. Administering care is much cheaper in Canada, for example, because there are standardized forms and processes for providers, facilities, and families to use to access and pay for care. The study authors estimate $600 billion a year is spent in the U.S. on administrative bureaucracy instead of clinical care. On a per person basis, this amounts to $844 spent per person for health insurance plan overhead in the U.S., versus $146 per person in Canada.

The U.S. System Pays Physicians More than Other Countries Do

It’s not just health plan administrative costs that drives U.S. spending higher, though as we have written before, streamlining forms and processes seems like an obvious place to start cutting costs. The U.S. also pays physicians more than other countries do. Anne Case and Angus Deaton – the economists who called attention to the rising number of “deaths of despair” in 2015 (and won a Nobel prize for their work that year) made headlines this week at the annual American Economic Association’s annual meeting when they said physicians are driving U.S. health care costs:

“We have half as many physicians per head as most European countries, yet they get paid two times as much, on average…” says Deaton. “Physicians are a giant rent-seeking conspiracy that’s taking money away from the rest of us, and yet everybody loves physicians. You can’t touch them.” (source: Washington Post).

Is this a Good Thing or a Bad Thing? (I ask in jest…)

Maybe the Internet coordinated these news reports, but the same day the Case/Deaton comments came out, several news outlets reported: Health care positions top 2020 list of best (paying) jobs! Indeed, 12 of the top 20 best paying jobs for 2020 are in health care. Here is the list from US News and World Report:

Best-Paying Jobs

  1. Anesthesiologist
  2. Surgeon
  3. Oral and Maxillofacial Surgeon
  4. Obstetrician and Gynecologist
  5. Orthodontist
  6. Psychiatrist
  7. Physician
  8. Prosthodontist
  9. Pediatrician
  10. Dentist
  11. Nurse Anesthetist
  12. Petroleum Engineer
  13. IT Manager
  14. Podiatrist
  15. Marketing Manager
  16. Financial Manager
  17. Pilot
  18. Lawyer
  19. Sales Manager
  20. Business Operations Manager

It’s good to see more attention being paid to costs, and it’s especially good to see research and data behind the alarming stories. We all know that health care costs are going up but if we really want to do something about it, we have to look at ALL health care costs. This kind of data is the first step toward policy making; let’s see what happens next.

In 2020, Patients Will Need to Be More Demanding

By |2019-12-27T12:25:53+00:00December 27th, 2019|Health Care Trends, Patients, Uncategorized|

In 2020, Patients Will Need to Be More Demanding

One of the last sessions I did as a panelist this year was part of a conference for patient groups across the country about patient rights related to transparency and access. My panel was asked to discuss current and proposed policies related to health care transparency and access to care, so I noted:

  1. Various state efforts to help patients get more information, especially about hospital prices;
  2. The November 2019 Department of Health and Human Services, the Department of Labor, and the Department of the Treasury’s proposed rule to improve transparency on the price consumers pay for certain health care services; and
  3. The importance of advocating for what the National Health Council calls Patient Factors of Value as payers rely more on so-called assessments of health care “value” from third-parties, such as the Institute for Clinical and Economic Review (ICER).

As I heard the audience questions, though, I was reminded of the limitations of policy making. Yes, policies should support patient transparency and access. No question. But perhaps more important is changing the way we act.

To put it bluntly, patients are going to need to be much more demanding.

And not just patients, but also anyone who supports patients, whether it be family members, friends, health care providers, employers, administrators, or legislators, will have to be much more demanding.

This means patients can’t wait for information to be provided by the health plan, hospital, or specialist.

We need to ask for information we want at every appointment, and before an appointment, as well.

We need to ask for information on cost-sharing. On treatment alternatives. On what evidence exists for the treatments. On how to get a second opinion about the diagnosis.

We need to ask about what supports are available during and after treatments.

We need to ask: What didn’t I ask? Who else should I talk to?

Making various kinds of health care information available may prove to be useful, but real change will need to be driven by patients and their supporters. Patient rights are essential, but in 2020 (and beyond), patients, and all of us who support them, will have to be much more demanding.

Giving thanks to…my mentors

By |2019-11-27T18:25:30+00:00November 27th, 2019|Uncategorized|

Giving thanks to…my mentors

As many of us take some time off these next few days to spend time with family or friends, we may also be reflecting on what we are thankful for. Each of us will make a list in our minds, even if we don’t share it “out loud.”

Recently I was asked to be a panelist for the Public Leadership Education Network (PLEN) as part of their annual Women in Health Policy Seminar. The seminar is for college women from across the U.S. considering a career in health policy and helps them learn how to make an impact in the legislative and political processes and how to expand their professional networks.

The panel topic was “Launching your Career” and one of the questions panelists were asked to answer was: “What do you view as a pivotal moment(s) that got you to where you are today in your health career?”

In thinking about my answer I realized there wasn’t really a single “pivotal moment,” but there were lots of “pivotal people” I had the opportunity to learn from and be led by over the years. During the session, I shared a few stories about mentors who had helped me along the way, and advised participants to find their pivotal people to build relationships and get honest feedback.

All of this inspired me to share “out loud” my sincerest thanks to the many mentors I have had who helped me be better than I was the day before. Sometimes it was a word of encouragement. Other times it was help making a difficult decision. Many times it was tough advice and honest feedback about something I was doing that was slowing down my growth. Every time it was a gift. Mentors don’t have to take the time, or make the room, or expend the energy they do. I am immensely grateful for the many pivotal people in my career who have given of themselves to make me better.

Thank you!