Effect of the Exclusion of Behavioral Health from Health Information Technology (HIT) Legislation on the Future of Integrated Health Care Deborah Cohen, MSW Abstract Past research has shown abundant comorbidity between physical chronic health conditions and mental illness. The focal point of the conversation to reduce cost is better care coordination through the implementation of health information technology (HIT). At the policy level, the Health Information Technology for Economic and Clinical Health Act of 2009 (HITECH Act) was implemented as a way to increase the implementation of HIT. However, behavioral health providers have been largely excluded from obtaining access to the funds provided by the HITECH Act. Without further intervention, disjointed care coordination between physical and behavioral health providers will continue.
Each year, nearly half of all Americans are affected by chronic health conditions with seven of every ten deaths being the result of chronic condition.1,2 This makes chronic health conditions the leading cause of death and disability in the USA. Additionally, they account for three quarters of health care spending.3 Perhaps not surprisingly, there is a great deal in the Patient Protection and Affordable Care Act of 2010 (ACA) that offers significant potential to better serve individuals with chronic health conditions with a major focus on better integration between primary care and behavioral healthcare.3 While it has been known for years that persons with serious mental illness (SMI) die younger than the general population, recent studies have revealed that the rates of morbidity and mortality have accelerated. People with SMI are now at risk of dying 25 years earlier than the general population from physical health conditions. In the prior two decades, this difference was only 10 to 15 years earlier.3–5 While it might be assumed that those with a SMI die from increased risks of suicide associated with their mental illness, research indicates otherwise; recent reports attribute the causes of increased morbidity and mortality for individuals with serious
Address correspondence to Deborah Cohen, MSW, Texas Institute for Excellence in Mental Health, School of Social Work, University of Texas at Austin, 1717 W. 6th Street, Austin, TX 78703, USA. Phone: +1-513-5046970; Email: [email protected].
)
Journal of Behavioral Health Services & Research, 2014. 1–5. c 2014 National Council for Behavioral Health. DOI 10.1007/s11414-014-9407-x
Exclusion from HIT
D. COHEN
mental illnesses to cardiovascular disease, diabetes, respiratory disease, and infectious diseases, including HIV/AIDS.3–6. Unfortunately, in the lengthy deliberation over healthcare reform, there has been relatively little discussion about the role of behavioral health. It appears that behavioral health will remain disconnected from the new healthcare developments in spite of some rhetoric to the contrary. Even though lip service has been paid to the value of integrating physical and behavioral health, behavioral health providers have been largely left out of the dialogue at both the national and state policy levels, as portions of healthcare reform are implemented.7,8 In the same fashion that a behavioral health diagnosis carries a heavy stigma, providers who choose to work in behavioral health have less status or authority than providers of physical healthcare.9–12 At a policy level, this hierarchy is demonstrated by the consideration of physicians when crafting the Health Information Technology for Economic and Clinical Health Act of 2009 (HITECH Act), as opposed to health care providers in the areas of behavioral and mental health. Thus, many of the providers who are essential to the well-being of many of the sickest individuals are left out of the debate. Overall, mental illness accounts for 15.4% of the total disease burden, yet mental health spending represents only 6.2% of the USA’s healthcare expenditures.12 Low public support for mental health funding was exhibited by the 1996 General Social Survey, which showed 68% of individuals support an increase in general health spending, but only 50% support an increase for mental health spending. Corrigan and Watson state “allocation decisions are affected by policy makers’ perceptions of the scarcity of resources, effectiveness of specific programs, needs of people who have problems that are served by these programs, and extent of personal responsibility for these problems.” 10 (p. 501) If the general public and policy makers believe mental health is not as essential as physical health, they are less likely to consider the role of mental health in the overall healthcare debate. In order to test the hypothesis that the general public believes mental health problems are less burdensome, Smith et al. asked participants to rate the level of burden for the following conditions: diabetes, below-the-knee amputation, partial blindness, depression, and schizophrenia.12 Participants were asked to consider how much they would pay to avoid the health condition. It was found that even though participants rated mental illness to be as or more burdensome than the physical health conditions, they were less willing to pay to avoid a mental illness as compared to the physical health conditions. The results build on previous work by Corrigan et al. that examined the public’s general unwillingness to allocate funds to treat mental illness, showing a clear preference to pay for general medical illnesses versus mental illnesses.10,11 Even though these studies do not directly assess the phenomena, the results suggest a connection to stigmatizing and devaluation of mental health treatment.12. There may be a variety of reasons for the failure of the current healthcare system to provide coordinated care to individuals with chronic health conditions. However, until the whole of the healthcare industry values the role of behavioral health as a necessary component in the way they value highly technical hospitals, the needs of individuals with chronic illness will likely be unmet. There is an implicit hierarchy within healthcare that is socialized in a variety of ways. The beliefs about lesser status are found among the general public, during educational preparation of providers, and within healthcare facilities. This can be seen in recent policies and through the unwillingness of insurers to pay for behavioral health services.10–13 Also, just as there are many examples of “not-in-my-backyard” reactions to the opening of new behavioral health facilities, there are many other ways that behavioral health has been left out of healthcare legislation. Even though a high number of the individuals served by behavioral health facilities live below the poverty line, funding to cover uncompensated care (through the Disproportionate Share Hospital Fund program) provides only a reduced rate to freestanding behavioral health inpatient units when compared to public hospitals. The crux of the conversation related to healthcare reform is directed at access and the implementation of health information technology (HIT) and electronic health records (EHR). Much
The Journal of Behavioral Health Services & Research
2014
of the health information technology for HITECH Act is based on the premise that with interoperable EHRs, providers will be able to better coordinate care of individuals with chronic health conditions and in turn improve the quality of care and decrease the cost of duplicate care.14,15 Prior to 2009, many family medicine practices experienced the same technology woes as behavioral health providers are currently experiencing, but with the enactment of HITECH, incentives were provided to assist them in the implementation or expansion of EHR for providers of Medicare and Medicaid services.15 The enactment of HITECH was based on two primary propositions: (1) there are barriers to the adoption of health information that need government intervention and (2) the widespread use of health information could improve the health and healthcare of the American public.14 In order to assist with the implementation, regional HIT extension centers were created and funding was targeted to incentivize the adoption of an EHR. Under HITECH, $27 billion in “meaningful use” funds were identified for eligible healthcare providers who met the requisite standards.14 “Meaningful use” concentrates on three main items: the use of a certified EHR in a meaningful manner, such as e-prescribing, the use of an EHR for electronic exchange of health information to improve quality of health care, and the use of certified EHR technology to submit clinical quality and other measures.15 Simply put, “meaningful use” means providers need to show that they are using certified EHR technology in ways that can be measured significantly in quality and in quantity. In order to qualify for HITECH payments, healthcare providers must first be an eligible hospital or eligible provider.1 If they plan to apply as an eligible hospital, the hospital can apply under Medicare. They also can apply if they are paid under the inpatient prospective payment system, are a Critical Access Hospital, or a Medicare Advantage plan or under Medicaid in the case of children’s hospitals or acute care hospitals with at least a 10% Medicaid volume.1 In addition, eligible individual healthcare professionals can apply as well. Since behavioral healthcare facilities do not qualify under the hospital (facility) provision, the only option is to apply through their eligible professionals. If the behavioral health organization has a prescriber on staff (psychiatrist or advanced practice nurse) that has a minimum 30% encounter volume of Medicaid clients, they are eligible to apply for “meaningful use.”15 Once the psychiatrist or advanced practice nurse applies as an eligible professional, payments can only be applied to one tax identification number, meaning if the individual works for a number of separate facilities, only one will be able to apply for the payments to improve their health information system.15 This option is causing a number of problems for behavioral health facilities. The primary barrier for behavioral health providers is that many organizations do not have a physician or nurse practitioner on staff, or they do not meet the Medicaid threshold for physician or nurse practitioners because their time is allocated to a variety of organizations. Even though most behavioral health organizations provide more than the required Medicaid volume, without specific eligible professionals to apply and assign the benefit to the organization, many behavioral health organizations do not have access to the meaningful use incentives. According to a survey by the National Council of Behavioral Healthcare, only 5% of community behavioral health organizations are currently able to meet the meaningful use requirements.8. It has been noted that the population with the greatest potential for improvement using interoperable EHRs are those with chronic health disorders. In a 2011 article, David Blumenthal the former National Coordinator of Health Information Technology (2009–2011), outlined four barriers to the implementation of EHRs that lead to the need for the HITECH Act. First, within the USA fee-for-service payment environment, there is no financial reward for implementing EHR that improves service quality and efficiency.14 Second, without guidance, most healthcare facilities do not have the resources or expertise to determine the best EHR to meet the needs of their facility. This leads to greater reluctance to make such a large purchase without increased certainty that it will function within the current workflow. Third, there is an obstacle to effectively sharing health information electronically between providers. With thousands of health information products
Exclusion from HIT
D. COHEN
already on the market, this has become a huge challenge. The goal of HITECH was to allow government to serve as a broker between products to facilitate technical and policy approaches to assist in the exchange of information. Fourth, there is great apprehension about how to ensure the privacy and security of EHRs. Without the certainty that a provider can ensure confidentiality, many facilities were apprehensive to becoming fully electronic.14 Each of these issues poses a specific threat to the behavioral health field implementing EHRs. There has been great attention paid to the sensitivity of behavioral health information due to the possible discriminatory reactions if the information were to be leaked to the wrong individual.16,17 Furthermore, behavioral health organizations have historically been behind the general healthcare field in implementing new technology, and this exclusion from HITECH will just lead to an even greater disparity.7,18 In the National Council survey, behavioral health facilities noted they could not afford the upfront cost to obtain an EHR and do not have the in-house technological expertise to select or implement the EHR. For each Medicaid-eligible professional on staff, the behavioral health organization can obtain up to $63,750 over 6 years.15 Access to these funds could change the entire landscape of technology within behavioral health organizations by improving the overall tracking and sharing of health data of individuals who have a SMI. This access will lead to obtaining the vision of a true health information exchange where providers from multiple organizations will be able to electronically coordinate care. In turn, individuals with comorbid mental health and physical health conditions will be better served, and there is a real opportunity for overall cost reduction. Therefore, behavioral healthcare stands to benefit tremendously from assistance towards eliminating barriers to EHR implementation. If all providers had access to HIT, individuals with a mental illness and comorbid chronic healthcare conditions would have the benefit of consistent communication (by way of HIT) among their providers.19 Unless behavioral health organizations are able to receive the same treatment as hospitals and obtain the same type of facility payments, they will continue to be “hampered in their efforts to join the rest of healthcare in achieving the Triple Aim of improving the patient experience of care, improving the health of the populations, and reducing the per-capita cost of healthcare.”7 (p.1) There is no way to reduce the strain on the healthcare system provided by those with chronic health conditions without including behavioral health in the intervention. Stated by the Executive Director of the National Council of Behavioral Healthcare, Linda Rosenberg: “Behavioral health organizations, serving more than eight million adults, children, and families with mental illnesses and addiction disorders, are ready and eager to adopt HIT to meet the goals of better healthcare, better health, and lower costs. But reaching these goals may prove impossible unless behavioral health achieves “parity” within healthcare and receives resources for the adoption of HIT.”7 (p.1). Obtaining an EHR is only the first step in the plan to improve health and healthcare that is laid out in HITECH and ACA. As a part of HITECH and the ACA, there is a push to establish Health Information Exchanges (HIE) to provide the framework through which health information from can be shared across health information systems with varying platforms.14 If behavioral health facilities are unable to obtain their own EHR, the incorporation of behavioral health information into general medical care cannot be effectively facilitated.7 This lack of incorporation presents a serious problem to service delivery for those with chronic health conditions. The goal of HIEs is to seamlessly exchange information among providers with the hope of ensuring a better system of care and reducing cost associated with duplicate services.3,7,18 The practical aspects of sharing health information, regardless of the location where health care services are obtained, can provide dramatic improvements in health care quality with improvements in medical decision-making and a reduction in redundancy.9 Even though the ACA notes that behavioral health is an important element, the lack of support to improve the technological infrastructure within the field of behavioral health will lead to limited participation in state-wide HIEs.7 Past research supports the notion that individuals who are provided services within a behavioral health facility are also likely to seek medication services elsewhere, meaning this population is in drastic need of HIE’s benefits. However, due to systemic barriers, the full capability of the HIE will not be realized.3,19.
The Journal of Behavioral Health Services & Research
2014
Consider the 80/20 principle: it has been stated that 20% of the American public consume 80% of healthcare services.20 At the core of the national healthcare conversation is the concern over the rising overall cost of healthcare. Individuals with a SMI and co-occurring chronic illnesses represent some of the most costly individuals to each state’s Medicaid rolls.3,21 Coordination across health care service systems would effectively target the most expensive individuals while increasing their quality of care. Thus, producing the greatest potential for economic and a societal payoff. The current structure of the HITECH Act does not consider this prospect for cost containment and, in turn, will miss out on a very vital opportunity to target the costliest 20%. There is a proposed solution to reducing the digital divide between behavioral health and the rest of healthcare. The Behavioral Health Information Technology Act (S. 539 and H.R. 6043) provides behavioral health organizations with the same financial incentives as their medical counterparts.7 Without a new emphasis on reducing the disparity in HIT between behavioral health providers and other healthcare providers, the goal to provide integrated health care will never be fully realized. Health information technology is the key to properly coordinating and integrating care for persons with both a behavioral health need and a co-occurring chronic health condition. However, based on financial barriers to purchasing an EHR, only 30% of all behavioral health providers have successfully or partially implemented any kind of EHR technology. If behavioral health providers are unable to keep up with the EHR adoption rate of other healthcare providers, soon it will become impossible to provide care coordination.7.
Implications for Behavioral Health Due to the diversity of services and wide variation in approaches for disorders and health conditions, it is unlikely that healthcare can be condensed into an easy-to-understand system or structure. Such a complicated system can be confusing to anyone. But it is specifically difficult for individuals with chronic health conditions who in many cases are solely responsible for communicating their varied treatment plans to multiple providers.19 In order to provide effective services to these individuals, it is important for all behavioral health providers to be mindful of the current trends in health care delivery and to be active participants in healthcare reform legislation. Within the hierarchy of healthcare professionals, individuals considered to be of lower status must move beyond their stigmatization and sequestration and demand a place at the table of public discourse. Behavioral health providers need to use the lessons learned from the adoption of the ACA and HITECH to ensure they are not left behind in designing future legislation. Without true representation of all the professionals and healthcare organizations that serve people with chronic healthcare needs, a holistic approach to healthcare will never be achieved. And, more critically, health care cost are likely to continually rise due to chronic conditions that might be better managed under coordinated and integrated care.
Acknowledgments The author would like to express thanks to Robert Walker of the University of Kentucky and Michael Lardieri of the National Council for Behavioral Health for their consultation during the development of this manuscript Conflict of interest There is no conflict of interest that is inherent to this manuscript and the author.
References 1. American Recovery and Reinvestment Act (ARRA), P.L. 111-5. (2009). Available online at http://frwebgate.access.gpo.gov/cgi-bin/ getdoc.cgi?dbname = 111_cong_bills&docid = f:h1enr.pdf. Accessed August 1, 2013.
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2. National Center for Chronic Disease Prevention and Health Promotion. Chronic Diseases The Power to Prevent, the Call to Control: At a Glance 2009. Washington (DC): CDC, 2009. 3. Center for Integrated Health Solutions. Behavioral Health Homes for People with Mental Health and Substance Use Conditions. Washington (DC): SAMHSA-HRSA, 2012. 4. National Association of State Mental Health Program Directors. Morbidity and Mortality in People with Serious Mental Illness. Washington (DC): NASMHPD, 2006. 5. Pincus HA, Page AE, Druss BG, et al. Can psychiatry cross the quality chasm? Improving the quality of health care for mental and substance use conditions. American Journal of Psychiatry. 2007; 164(5):712-9. 6. Druss BG, Zhao L, Von Esenwein S, et al. Understanding excess mortality in persons with mental illness: 17-year follow up of a nationally representative US survey. Medical Care. 2011; 49(6): 599-604. 7. Dickey B, Normand SL, Weiss RD, et al. Medical Morbidity, Mental Illness, and Substance Use Disorders. Psychiatric Services. 2002; 53(7): 861-867. 8. National Council of Behavioral Healthcare. HIT adoption and readiness for meaningful use in community mental health. Report on 2012 National Council survey. Washington (DC): National Council of Behavioral Healthcare, 2012. 9. Pating DR, Miller MM, Goplerud E, et al. New systems of care for substance use disorders: treatment, finance, and technology under health reform. Psychiatry Clinics of North America. 2012; 35: 327–356. 10. Corrigan PW, Watson AC, Warpinski AC, et al. Stigmatizing attitudes about mental illness and allocation of resources to mental health services. Community Mental Health Journal. 2004; 40 (4): 297-307. 11. Corrigan PW, Watson, AC. Factors that explain how policy makers distribute resources for mental health services. Psychiatric Services. 2003; 54 (4): 501-507. 12. Smith DM, Damschroder LJ, Kim SY, et al. What it’s worth? Public willingness to pay to avoid mental illnesses compared with general medical illnesses. Psychiatric Services. 2012; 63 (4): 319-324. 13. Hanson KW. Public opinion and the mental health parity debate: lessons from the survey literature. Psychiatric Services. 1998; 49: 1059-1066. 14. Blumenthal D. Wiring the health system- Origins and provisions of a new federal program. Part one of two. The New England Journal of Medicine. 2011; 365 (24): 2323-2329. 15. Health Information Technology for Economic and Clinical Health (HITECH) Act, Title XIII of Division A and Title IV of Division B of the American Recovery and Reinvestment Act of 2009 ( HYPERLINK "http://itlaw.wikia.com/wiki/ARRA" \o "ARRA" ARRA ), Pub. L. No. 111-5. 16. RothsteCBRSin MA. The Hippocratic bargain and health information technology. Journal of Law, Medicine and Ethics. 2010; 7-13. 17. Clemens NA. Privacy, Consent, and the Electronic Mental Health. Record: The Person vs. the System. Journal of Psychiatric Practice. 2012; 18 (1): 46-50. 18. Levin BL, Hanson A. Mental Health Informatics. New York: Taylor Francis Group, 2011. 19. Gruman JC. Making health information sing for people with chronic health conditions. Journal of Preventative Medicine 2011; 40 (5S2): S238-S240. 20. Koch R. The 80/20 Principle: The Secret of Achieving More with Less. New York: Doubleday Publishing, 1998. 21. Druss BG, Marcus SC, Olfson M, et al. The most expensive medical conditions in America. Health Affairs. 2002; 21(4): 105-111.
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2014
Each year, nearly half of all Americans are affected by chronic health conditions with seven of every ten deaths being the result of chronic condition.1,2 This makes chronic health conditions the leading cause of death and disability in the USA. Additionally, they account for three quarters of health care spending.3 Perhaps not surprisingly, there is a great deal in the Patient Protection and Affordable Care Act of 2010 (ACA) that offers significant potential to better serve individuals with chronic health conditions with a major focus on better integration between primary care and behavioral healthcare.3 While it has been known for years that persons with serious mental illness (SMI) die younger than the general population, recent studies have revealed that the rates of morbidity and mortality have accelerated. People with SMI are now at risk of dying 25 years earlier than the general population from physical health conditions. In the prior two decades, this difference was only 10 to 15 years earlier.3–5 While it might be assumed that those with a SMI die from increased risks of suicide associated with their mental illness, research indicates otherwise; recent reports attribute the causes of increased morbidity and mortality for individuals with serious
Address correspondence to Deborah Cohen, MSW, Texas Institute for Excellence in Mental Health, School of Social Work, University of Texas at Austin, 1717 W. 6th Street, Austin, TX 78703, USA. Phone: +1-513-5046970; Email: [email protected].
)
Journal of Behavioral Health Services & Research, 2014. 1–5. c 2014 National Council for Behavioral Health. DOI 10.1007/s11414-014-9407-x
Exclusion from HIT
D. COHEN
mental illnesses to cardiovascular disease, diabetes, respiratory disease, and infectious diseases, including HIV/AIDS.3–6. Unfortunately, in the lengthy deliberation over healthcare reform, there has been relatively little discussion about the role of behavioral health. It appears that behavioral health will remain disconnected from the new healthcare developments in spite of some rhetoric to the contrary. Even though lip service has been paid to the value of integrating physical and behavioral health, behavioral health providers have been largely left out of the dialogue at both the national and state policy levels, as portions of healthcare reform are implemented.7,8 In the same fashion that a behavioral health diagnosis carries a heavy stigma, providers who choose to work in behavioral health have less status or authority than providers of physical healthcare.9–12 At a policy level, this hierarchy is demonstrated by the consideration of physicians when crafting the Health Information Technology for Economic and Clinical Health Act of 2009 (HITECH Act), as opposed to health care providers in the areas of behavioral and mental health. Thus, many of the providers who are essential to the well-being of many of the sickest individuals are left out of the debate. Overall, mental illness accounts for 15.4% of the total disease burden, yet mental health spending represents only 6.2% of the USA’s healthcare expenditures.12 Low public support for mental health funding was exhibited by the 1996 General Social Survey, which showed 68% of individuals support an increase in general health spending, but only 50% support an increase for mental health spending. Corrigan and Watson state “allocation decisions are affected by policy makers’ perceptions of the scarcity of resources, effectiveness of specific programs, needs of people who have problems that are served by these programs, and extent of personal responsibility for these problems.” 10 (p. 501) If the general public and policy makers believe mental health is not as essential as physical health, they are less likely to consider the role of mental health in the overall healthcare debate. In order to test the hypothesis that the general public believes mental health problems are less burdensome, Smith et al. asked participants to rate the level of burden for the following conditions: diabetes, below-the-knee amputation, partial blindness, depression, and schizophrenia.12 Participants were asked to consider how much they would pay to avoid the health condition. It was found that even though participants rated mental illness to be as or more burdensome than the physical health conditions, they were less willing to pay to avoid a mental illness as compared to the physical health conditions. The results build on previous work by Corrigan et al. that examined the public’s general unwillingness to allocate funds to treat mental illness, showing a clear preference to pay for general medical illnesses versus mental illnesses.10,11 Even though these studies do not directly assess the phenomena, the results suggest a connection to stigmatizing and devaluation of mental health treatment.12. There may be a variety of reasons for the failure of the current healthcare system to provide coordinated care to individuals with chronic health conditions. However, until the whole of the healthcare industry values the role of behavioral health as a necessary component in the way they value highly technical hospitals, the needs of individuals with chronic illness will likely be unmet. There is an implicit hierarchy within healthcare that is socialized in a variety of ways. The beliefs about lesser status are found among the general public, during educational preparation of providers, and within healthcare facilities. This can be seen in recent policies and through the unwillingness of insurers to pay for behavioral health services.10–13 Also, just as there are many examples of “not-in-my-backyard” reactions to the opening of new behavioral health facilities, there are many other ways that behavioral health has been left out of healthcare legislation. Even though a high number of the individuals served by behavioral health facilities live below the poverty line, funding to cover uncompensated care (through the Disproportionate Share Hospital Fund program) provides only a reduced rate to freestanding behavioral health inpatient units when compared to public hospitals. The crux of the conversation related to healthcare reform is directed at access and the implementation of health information technology (HIT) and electronic health records (EHR). Much
The Journal of Behavioral Health Services & Research
2014
of the health information technology for HITECH Act is based on the premise that with interoperable EHRs, providers will be able to better coordinate care of individuals with chronic health conditions and in turn improve the quality of care and decrease the cost of duplicate care.14,15 Prior to 2009, many family medicine practices experienced the same technology woes as behavioral health providers are currently experiencing, but with the enactment of HITECH, incentives were provided to assist them in the implementation or expansion of EHR for providers of Medicare and Medicaid services.15 The enactment of HITECH was based on two primary propositions: (1) there are barriers to the adoption of health information that need government intervention and (2) the widespread use of health information could improve the health and healthcare of the American public.14 In order to assist with the implementation, regional HIT extension centers were created and funding was targeted to incentivize the adoption of an EHR. Under HITECH, $27 billion in “meaningful use” funds were identified for eligible healthcare providers who met the requisite standards.14 “Meaningful use” concentrates on three main items: the use of a certified EHR in a meaningful manner, such as e-prescribing, the use of an EHR for electronic exchange of health information to improve quality of health care, and the use of certified EHR technology to submit clinical quality and other measures.15 Simply put, “meaningful use” means providers need to show that they are using certified EHR technology in ways that can be measured significantly in quality and in quantity. In order to qualify for HITECH payments, healthcare providers must first be an eligible hospital or eligible provider.1 If they plan to apply as an eligible hospital, the hospital can apply under Medicare. They also can apply if they are paid under the inpatient prospective payment system, are a Critical Access Hospital, or a Medicare Advantage plan or under Medicaid in the case of children’s hospitals or acute care hospitals with at least a 10% Medicaid volume.1 In addition, eligible individual healthcare professionals can apply as well. Since behavioral healthcare facilities do not qualify under the hospital (facility) provision, the only option is to apply through their eligible professionals. If the behavioral health organization has a prescriber on staff (psychiatrist or advanced practice nurse) that has a minimum 30% encounter volume of Medicaid clients, they are eligible to apply for “meaningful use.”15 Once the psychiatrist or advanced practice nurse applies as an eligible professional, payments can only be applied to one tax identification number, meaning if the individual works for a number of separate facilities, only one will be able to apply for the payments to improve their health information system.15 This option is causing a number of problems for behavioral health facilities. The primary barrier for behavioral health providers is that many organizations do not have a physician or nurse practitioner on staff, or they do not meet the Medicaid threshold for physician or nurse practitioners because their time is allocated to a variety of organizations. Even though most behavioral health organizations provide more than the required Medicaid volume, without specific eligible professionals to apply and assign the benefit to the organization, many behavioral health organizations do not have access to the meaningful use incentives. According to a survey by the National Council of Behavioral Healthcare, only 5% of community behavioral health organizations are currently able to meet the meaningful use requirements.8. It has been noted that the population with the greatest potential for improvement using interoperable EHRs are those with chronic health disorders. In a 2011 article, David Blumenthal the former National Coordinator of Health Information Technology (2009–2011), outlined four barriers to the implementation of EHRs that lead to the need for the HITECH Act. First, within the USA fee-for-service payment environment, there is no financial reward for implementing EHR that improves service quality and efficiency.14 Second, without guidance, most healthcare facilities do not have the resources or expertise to determine the best EHR to meet the needs of their facility. This leads to greater reluctance to make such a large purchase without increased certainty that it will function within the current workflow. Third, there is an obstacle to effectively sharing health information electronically between providers. With thousands of health information products
Exclusion from HIT
D. COHEN
already on the market, this has become a huge challenge. The goal of HITECH was to allow government to serve as a broker between products to facilitate technical and policy approaches to assist in the exchange of information. Fourth, there is great apprehension about how to ensure the privacy and security of EHRs. Without the certainty that a provider can ensure confidentiality, many facilities were apprehensive to becoming fully electronic.14 Each of these issues poses a specific threat to the behavioral health field implementing EHRs. There has been great attention paid to the sensitivity of behavioral health information due to the possible discriminatory reactions if the information were to be leaked to the wrong individual.16,17 Furthermore, behavioral health organizations have historically been behind the general healthcare field in implementing new technology, and this exclusion from HITECH will just lead to an even greater disparity.7,18 In the National Council survey, behavioral health facilities noted they could not afford the upfront cost to obtain an EHR and do not have the in-house technological expertise to select or implement the EHR. For each Medicaid-eligible professional on staff, the behavioral health organization can obtain up to $63,750 over 6 years.15 Access to these funds could change the entire landscape of technology within behavioral health organizations by improving the overall tracking and sharing of health data of individuals who have a SMI. This access will lead to obtaining the vision of a true health information exchange where providers from multiple organizations will be able to electronically coordinate care. In turn, individuals with comorbid mental health and physical health conditions will be better served, and there is a real opportunity for overall cost reduction. Therefore, behavioral healthcare stands to benefit tremendously from assistance towards eliminating barriers to EHR implementation. If all providers had access to HIT, individuals with a mental illness and comorbid chronic healthcare conditions would have the benefit of consistent communication (by way of HIT) among their providers.19 Unless behavioral health organizations are able to receive the same treatment as hospitals and obtain the same type of facility payments, they will continue to be “hampered in their efforts to join the rest of healthcare in achieving the Triple Aim of improving the patient experience of care, improving the health of the populations, and reducing the per-capita cost of healthcare.”7 (p.1) There is no way to reduce the strain on the healthcare system provided by those with chronic health conditions without including behavioral health in the intervention. Stated by the Executive Director of the National Council of Behavioral Healthcare, Linda Rosenberg: “Behavioral health organizations, serving more than eight million adults, children, and families with mental illnesses and addiction disorders, are ready and eager to adopt HIT to meet the goals of better healthcare, better health, and lower costs. But reaching these goals may prove impossible unless behavioral health achieves “parity” within healthcare and receives resources for the adoption of HIT.”7 (p.1). Obtaining an EHR is only the first step in the plan to improve health and healthcare that is laid out in HITECH and ACA. As a part of HITECH and the ACA, there is a push to establish Health Information Exchanges (HIE) to provide the framework through which health information from can be shared across health information systems with varying platforms.14 If behavioral health facilities are unable to obtain their own EHR, the incorporation of behavioral health information into general medical care cannot be effectively facilitated.7 This lack of incorporation presents a serious problem to service delivery for those with chronic health conditions. The goal of HIEs is to seamlessly exchange information among providers with the hope of ensuring a better system of care and reducing cost associated with duplicate services.3,7,18 The practical aspects of sharing health information, regardless of the location where health care services are obtained, can provide dramatic improvements in health care quality with improvements in medical decision-making and a reduction in redundancy.9 Even though the ACA notes that behavioral health is an important element, the lack of support to improve the technological infrastructure within the field of behavioral health will lead to limited participation in state-wide HIEs.7 Past research supports the notion that individuals who are provided services within a behavioral health facility are also likely to seek medication services elsewhere, meaning this population is in drastic need of HIE’s benefits. However, due to systemic barriers, the full capability of the HIE will not be realized.3,19.
The Journal of Behavioral Health Services & Research
2014
Consider the 80/20 principle: it has been stated that 20% of the American public consume 80% of healthcare services.20 At the core of the national healthcare conversation is the concern over the rising overall cost of healthcare. Individuals with a SMI and co-occurring chronic illnesses represent some of the most costly individuals to each state’s Medicaid rolls.3,21 Coordination across health care service systems would effectively target the most expensive individuals while increasing their quality of care. Thus, producing the greatest potential for economic and a societal payoff. The current structure of the HITECH Act does not consider this prospect for cost containment and, in turn, will miss out on a very vital opportunity to target the costliest 20%. There is a proposed solution to reducing the digital divide between behavioral health and the rest of healthcare. The Behavioral Health Information Technology Act (S. 539 and H.R. 6043) provides behavioral health organizations with the same financial incentives as their medical counterparts.7 Without a new emphasis on reducing the disparity in HIT between behavioral health providers and other healthcare providers, the goal to provide integrated health care will never be fully realized. Health information technology is the key to properly coordinating and integrating care for persons with both a behavioral health need and a co-occurring chronic health condition. However, based on financial barriers to purchasing an EHR, only 30% of all behavioral health providers have successfully or partially implemented any kind of EHR technology. If behavioral health providers are unable to keep up with the EHR adoption rate of other healthcare providers, soon it will become impossible to provide care coordination.7.
Implications for Behavioral Health Due to the diversity of services and wide variation in approaches for disorders and health conditions, it is unlikely that healthcare can be condensed into an easy-to-understand system or structure. Such a complicated system can be confusing to anyone. But it is specifically difficult for individuals with chronic health conditions who in many cases are solely responsible for communicating their varied treatment plans to multiple providers.19 In order to provide effective services to these individuals, it is important for all behavioral health providers to be mindful of the current trends in health care delivery and to be active participants in healthcare reform legislation. Within the hierarchy of healthcare professionals, individuals considered to be of lower status must move beyond their stigmatization and sequestration and demand a place at the table of public discourse. Behavioral health providers need to use the lessons learned from the adoption of the ACA and HITECH to ensure they are not left behind in designing future legislation. Without true representation of all the professionals and healthcare organizations that serve people with chronic healthcare needs, a holistic approach to healthcare will never be achieved. And, more critically, health care cost are likely to continually rise due to chronic conditions that might be better managed under coordinated and integrated care.
Acknowledgments The author would like to express thanks to Robert Walker of the University of Kentucky and Michael Lardieri of the National Council for Behavioral Health for their consultation during the development of this manuscript Conflict of interest There is no conflict of interest that is inherent to this manuscript and the author.
References 1. American Recovery and Reinvestment Act (ARRA), P.L. 111-5. (2009). Available online at http://frwebgate.access.gpo.gov/cgi-bin/ getdoc.cgi?dbname = 111_cong_bills&docid = f:h1enr.pdf. Accessed August 1, 2013.
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2. National Center for Chronic Disease Prevention and Health Promotion. Chronic Diseases The Power to Prevent, the Call to Control: At a Glance 2009. Washington (DC): CDC, 2009. 3. Center for Integrated Health Solutions. Behavioral Health Homes for People with Mental Health and Substance Use Conditions. Washington (DC): SAMHSA-HRSA, 2012. 4. National Association of State Mental Health Program Directors. Morbidity and Mortality in People with Serious Mental Illness. Washington (DC): NASMHPD, 2006. 5. Pincus HA, Page AE, Druss BG, et al. Can psychiatry cross the quality chasm? Improving the quality of health care for mental and substance use conditions. American Journal of Psychiatry. 2007; 164(5):712-9. 6. Druss BG, Zhao L, Von Esenwein S, et al. Understanding excess mortality in persons with mental illness: 17-year follow up of a nationally representative US survey. Medical Care. 2011; 49(6): 599-604. 7. Dickey B, Normand SL, Weiss RD, et al. Medical Morbidity, Mental Illness, and Substance Use Disorders. Psychiatric Services. 2002; 53(7): 861-867. 8. National Council of Behavioral Healthcare. HIT adoption and readiness for meaningful use in community mental health. Report on 2012 National Council survey. Washington (DC): National Council of Behavioral Healthcare, 2012. 9. Pating DR, Miller MM, Goplerud E, et al. New systems of care for substance use disorders: treatment, finance, and technology under health reform. Psychiatry Clinics of North America. 2012; 35: 327–356. 10. Corrigan PW, Watson AC, Warpinski AC, et al. Stigmatizing attitudes about mental illness and allocation of resources to mental health services. Community Mental Health Journal. 2004; 40 (4): 297-307. 11. Corrigan PW, Watson, AC. Factors that explain how policy makers distribute resources for mental health services. Psychiatric Services. 2003; 54 (4): 501-507. 12. Smith DM, Damschroder LJ, Kim SY, et al. What it’s worth? Public willingness to pay to avoid mental illnesses compared with general medical illnesses. Psychiatric Services. 2012; 63 (4): 319-324. 13. Hanson KW. Public opinion and the mental health parity debate: lessons from the survey literature. Psychiatric Services. 1998; 49: 1059-1066. 14. Blumenthal D. Wiring the health system- Origins and provisions of a new federal program. Part one of two. The New England Journal of Medicine. 2011; 365 (24): 2323-2329. 15. Health Information Technology for Economic and Clinical Health (HITECH) Act, Title XIII of Division A and Title IV of Division B of the American Recovery and Reinvestment Act of 2009 ( HYPERLINK "http://itlaw.wikia.com/wiki/ARRA" \o "ARRA" ARRA ), Pub. L. No. 111-5. 16. RothsteCBRSin MA. The Hippocratic bargain and health information technology. Journal of Law, Medicine and Ethics. 2010; 7-13. 17. Clemens NA. Privacy, Consent, and the Electronic Mental Health. Record: The Person vs. the System. Journal of Psychiatric Practice. 2012; 18 (1): 46-50. 18. Levin BL, Hanson A. Mental Health Informatics. New York: Taylor Francis Group, 2011. 19. Gruman JC. Making health information sing for people with chronic health conditions. Journal of Preventative Medicine 2011; 40 (5S2): S238-S240. 20. Koch R. The 80/20 Principle: The Secret of Achieving More with Less. New York: Doubleday Publishing, 1998. 21. Druss BG, Marcus SC, Olfson M, et al. The most expensive medical conditions in America. Health Affairs. 2002; 21(4): 105-111.
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