This is the statement submitted to the Green Mountain Care Board

Tuesday, May 15, 2012 by Rilla A. Murray, MS (Soc. Adm.), DrPH

Good afternoon. My name is Rilla Murray. I am a social worker. I am here today as the Executive Director of the Vermont Chapter of the National Association of Social Workers. Our chapter has over 500 members, the vast majority of whom hold a master's degree in social work. Many are licensed clinical social workers, but all of them as individuals and professionals are touched directly or indirectly by the realities of health care delivery and payment systems.

As an organization, NASW-VT fully supports the goals of health care reform in Vermont because we believe their realization will lead us to:

• universally accessible health care

•  that is integrated to meet the needs of the patient,

• who participates fully in a shared decision-making and

• carries shared responsibility for results.

Thank you for the opportunity to consider with you pathways that will result in achieving these goals. My remarks are in two parts. First, I want to paint a picture of where social workers sit in the world of health and mental health services today. Then I will make some observations about our current situation and offer recommendations intended to respond to those observations. Finally, I will highlight the recommendations that I believe will have the greatest immediate impact.

Where are social workers in this picture?

Social workers are the single largest group of providers among mental health professionals. In Vermont there are 1518 licensed clinical social workers (LICSWs). They are in increasingly high demand to respond to the needs of returning veterans, the growing population of older adults, families affected by the economic downtown, and a growing public acknowledgement that a sizeable number of people are suffering from addictive processes.

Although social work as a profession encompasses political advocacy as well as clinical services, the only social workers who participate in third-party payment systems for health care in Vermont are Licensed Clinical Social Workers, or LICSWs.

·         LICSWs are salaried employees in agencies and organizations, such as hospitals, primary care, community mental health centers, residential services, and home health and hospice services.

·         LICSWs also are small business owners operating solo or in group private practice. As small business owners they have all the same problems that other small businesses have, including how to find affordable health care insurance.

·         Regardless of where they are employed, LICSWs doing clinical work offer evidence-based assessment, diagnosis, and treatment to individuals of all ages, couples, families, and groups. Their clients exhibit a wide range of mental health problems, from mild to severe. Many clients have co-morbidities such as chronic medical conditions and addictions.

Observations and Recommendations to Assure Integrated, Patient-Centered Care

I am not the first person and I won't be the last to observe that in Vermont access to mental health and substance abuse services (MH/SA) is inadequate. The Act 129 Task Force documented this reality for several years in annual reports to the legislature. Care-seeking patients, the Health Care Ombudsman, and providers acting as patient advocates have testified to this fact in one forum after another. Resolving the access issues alone will not produce integrated care, but it is an essential component and a good place to start. I want to offer three observations and several recommendations for your consideration.

Observation:  Social stigma is a root cause of the access problem and the disorganized, disconnected, and diagnosis-centered nature of the health services we have today.

Socially, and as expressed in our current array of health services, we readily accept the need to offer and seek attention for conditions we believe are fortuitous, such as a heart attack, injuries at work, cancer and other diseases. We are much less willing to offer and seek attention for depression and anxiety (and other mental illnesses) because as a culture we have been under the misapprehension that these are signs of personal weakness. The result is an isolated patchwork of mental health services delivered by diagnosis, in large part separately from physical health services.

We know that as many as 50% of patients who present in primary care have an underlying mental health problem they have not acknowledged or no provider has asked them about. These individuals incur costs for testing and treatments that do not address the causes of their problems. The integration of patient-centered care, by normalizing the inclusion of mental health in assessment, diagnosis, and treatment planning, would work both to reduce stigma and cut long-term costs. To be effective, this normalizing process has to be supported by a simple and prompt referral or incorporation of mental health services in the plan of care. Co-locating mental health services within the medical setting or the same building would significantly reduce the stigma associated with seeking those services. While we cannot legislate culture change or outlaw stigma, we can take some specific steps to reduce stigma so that mental health is seen as only one facet of a very complex person who is seeking care.

·         Make it "normal" to look at mental health. Expect and reward all primary care providers and emergency departments to include in patient assessments a screen for common mental health conditions, such as depression and anxiety, whether or not that is the presenting problem.

·         Create financial incentives to incorporate mental health services within medical practice settings or for co-location of medical and mental health services.

Observation: The path an individual takes between recognizing the need for help and getting help is an obstacle course that would test even the emotionally most sturdy of individuals.

Another aspect of Vermont's access problem is that when an individual seeks help for mental and emotional problems, a variety of barriers stand in her way. First, due largely to repeated budget cuts, the visible public system of community mental health centers has moved away from providing primary mental health treatment to adults. Fewer services are available than previously. When they are offered, waiting lists are so long as to be a significant barrier to care. For commercially insured individuals, the insurance carrier provides a list of qualified providers. While the validity of in-network provider lists has improved in recent years, they offer no insight as to availability or specialty. The private sector works like most small businesses--word of mouth, telephone and website directory listings, discreet advertising.

An individual in crisis has to make a series of phone calls looking for someone who has an opening reasonably soon, who works with people with the type of problem the person describes, and who accepts the person's insurance.

The weight of stigma--which translates to shame in an individual--and the emotional fragility of a person in crisis combine to make this approach simply unworkable. Organized attempts to facilitate links between recognized need and the provision of care, though laudable, have failed for a variety of reasons. One reason is that they do not address the issue of which providers have openings within a reasonable time period, i.e., two weeks. Providers are listed who are not taking new patients or have waiting lists. Static lists get out of date quickly.

Another reason the directory approach has failed that is pertinent to our discussion today is that medical providers prefer to refer their patients to individuals they have met and have some reason to believe can meet a particular patient's needs. This is no different for MH/SA than for surgery, except medical providers are less likely to know MH/SA providers well and are understandably reluctant to refer to someone based on a phone book listing. What often happens is that the medical provider tells her patient that evidence shows that talk therapy is effective in dealing with problems causing symptoms of depression and anxiety and even suggests the patient find a therapist. The burden of finding appropriate help is placed on the shoulders of the person least able to bear it.

Everyone in this picture--the patient seeking care, his medical provider, and mental health providers--needs help. I believe this is one of the key points in a care process where effective systems could have a significant, positive impact on integration of MH/SA into medical care. At the moment we could liken this point to a transition of care, a point we all know requires close attention. Our goal is eventually to make this one of many points of connection in offering patient-centered care.

Recommendation:

·         Establish a dynamic, all-payer referral and scheduling system to facilitate access to MH/SA care when care is needed. This system itself would be readily accessible by telephone and Internet from a medical care provider's office. It would reflect the real-time availability and special expertise of MH/SA providers within a reasonable distance. To assure its use, there must be supplemental and regular regional and local opportunities for providers to become known to one another (which might include shared continuing education events). The measure of its success will be an increased proportion of completed referrals and shared follow-up communication among providers.

Observation:  Cost-sharing contributes to inadequate access.

Access to MH/SA care is particularly affected by member cost-sharing designs in commercial insurance plans and in Medicare. Unlike a one-time contact with a surgeon which might incur a single specialty provider co-pay as high as $50, getting into and staying in MH/SA care can involve four or more co-pays per month. This year H. 559 established that co-pays for primary MH/SA services should be no higher than for primary medical care. Once this is implemented it will provide some relief from cost-sharing burdens which cause people to drop out of care prematurely for financial reasons or never get into care in the first place. Out-patient MH/SA treatment helps to prevent more expensive in-patient care. It is also an important and relatively low-cost component of strategies to prevent, manage and resolve issues known to underlie medical conditions such as obesity, poorly controlled diabetes, hypertension, and chronic pain. We need to find ways to promote rather than deter its use.

Recommendation:

·         Forgive cost-sharing for MH/SA services arising in an integrated care setting or from a primary care provider direct referral.

Observation: The professional MH/SA workforce is inadequate to meet current needs and is about to get smaller.

Long waiting lists at community mental health centers and the lack of openings among private practitioners suggest that our workforce is not adequate to meet our current expressed needs for MH/SA services. Act 129 Task Force Reports have suggested that among the commercially insured population we are serving one in seven people when we could expect that one in four might have a basis for needing service.  Available published data on licensed providers is not detailed enough to tell us if they are actually doing clinical work, are working full-time or part-time, or where they are working. The distribution of qualified MH/SA professionals in the state is skewed toward the more populated areas. Rural areas, where other community support services may also be in shorter supply, are especially affected. In the short-term, we need to find ways to overcome the barrier of distance for rural residents.

Social workers as a group are significantly older and enter this workforce at later life stages than the civilian population as a whole. The average age nationally in 2009 was 49, with approximately 60% over the age of 45. In Vermont, the workforce is directly threatened by the realities of our state's demographics. Five years ago a survey of LICSWs (the vast majority in mental health and health care) revealed that 40% of them intended to retire within five to ten years. In other words, we are about to see large numbers of our most experienced clinicians leave the workforce at a time when the Bureau of Labor Statistics reports that we can expect a 25% increased demand for social work services due to the growing proportion of Vermonters who are living to advanced ages. A bad economy has undoubtedly delayed some of those planned retirements, but the problem remains.

As with other licensed groups, LICSWs have suffered downward pressure on third-party reimbursements for several years. In addition, self-employed LICSWs are paid only for the time they spend with clients in treatment. They are not paid for time they spend advocating for their patients with third-party payers. They are not paid -- and this is especially critical in working with children -- for collateral contacts and going to meetings required to provide quality care.

Some self-employed social workers have stopped participating in the third party payment system because of these pressures. Others are leaving the field or taking salaried positions. It is not enough for a benefits plan to include services if there is not a workforce prepared to provide those services at the reimbursement levels paid. In fact, it is an empty promise.

Vermont does not offer incentives, such as loan forgiveness or paid supervision, to newly qualified social workers who choose to practice here.

Recommendations:

·         Pay providers for all aspects of the care they provide at levels commensurate with training and experience and competitive with that in other states, with the goal of attracting providers to Vermont and assuring an adequate professional workforce.

·         Establish financial and professional incentives for newly qualified providers to practice in Vermont, including but not limited to loan repayment programs, reimbursement for clinical supervision required to obtain a clinical license, assistance through co-location with the costs of establishing a practice, compensation for continuing education that assures they have the benefit of evidenced-based research for practice once they leave school.

Summary

In summary, NASW-VT fully supports the goal of integrating mental health and substance abuse treatment into our health care system. We believe that this is not only an issue of social justice but also one of creating a productive and effective community. I have offered several observations and related recommendations. Of these, I believe the following three recommendations would have the greatest immediate impact in achieving our shared goal of integrated care:

1.       Make it "normal" to look at mental health. Expect and reward all primary care providers and emergency departments to include in patient assessments a screen for common mental health conditions, such as depression and anxiety, whether or not that is the presenting problem.

2.       Establish a dynamic, all-payer referral and scheduling system to facilitate access to MH/SA care when care is needed. This system itself would be readily accessible by telephone and Internet from a medical care provider's office and the MH/SA provider's office. It would reflect the real-time availability and special expertise of MH/SA providers within a reasonable distance. To assure its use, there must be regular, supplemental local opportunities for providers to become known to one another (which might include shared continuing education events). The measure of its success will be an increased proportion of completed referrals and shared follow-up communication among providers.

3.       Pay providers for all aspects of the care they provide at levels commensurate with training and experience and competitive with that in other states.

Thank you again for this opportunity to explore ways to move toward the integration of mental health into physical health care. I welcome your questions and observations.

For further discussion, please contact me at 802-223-1713 or rmurray@naswvt.org.