Testimony to the Institute of Medicine Committee on Crossing the Quality Chasm: An Adaptation to Mental Health and Addictive Disorders

National Association of Social Workers
Submitted by Elizabeth J. Clark, PhD, ACSW, MPH
Executive Director

Provided by Mickey J.W. Smith, MSW
Senior Policy Associate for Behavioral Health

July 14, 2004

Background

The National Association of Social Workers (NASW) is grateful for the invitation to testify before the Institute of Medicine Committee on “Crossing the Quality Chasm: An Adaptation to Mental Health and Addictive Disorders.” As the largest professional association representing social workers in the world—with 153,000 members—NASW is able to speak with a unified voice for the profession. Staff members from NASW reviewed the background materials relevant to the IOM committee's task to address the quality issues in behavioral health care (mental health and substance use disorders). The Association also was involved with the development of the testimony provided on April 26, 2004 on behalf of the Alliance of Mental Health Professions, and fully supports its recommendations.

The need to transform mental health care in America has been described in a thorough manner by the President's New Freedom Commission (NFC) on Mental Health, which released their final report in July 2003. According to this report, the current mental health delivery system is fragmented and in disarray; access to quality mental health care in many communities is substandard, resulting in problems for individuals with mental illness. While there are major problems with the current mental health care system, there is a great deal of hope for consumers of mental health services. There appears to be a great deal of focus on the mental health care system, as demonstrated by these efforts. However, previous activities—the 1978 President's Commission on Mental Health and the 1999 U.S. Surgeon General's report on mental health, which received a great deal of attention initially—resulted in too little change in mental health care in the United States.

Responses

In its testimony today, NASW will provide the social work perspective on the three questions posed to the provider panels, and elaborate on key points presented by the Alliance of Mental Health Professions in April. It is our intention to address these questions using the six aims of the initial report as a framework.

1. In what ways does the quality of MH and/or SA care diverge from the IOM's six quality aims?

One of the key defects of the behavioral health care system is that current funding restrictions create large barriers to the delivery of quality services. Public and private insurers often do not reimburse providers for evidence-based services; meanwhile, services that have been demonstrated to be ineffective are funded and/or reimbursed. Many insurers establish significant and discriminatory limits on behavioral health care and often restrict access to qualified providers. Furthermore, public insurers (e.g., Medicaid) are decreasing payment rates for behavioral health services, creating an environment in which many professionals are making the decision to no longer provide services to individuals covered by such programs.

The current financial barriers posed by many payors are having a negative impact on the delivery of behavioral health care in this country. Increasing numbers of providers are making the decision to no longer provide services to individuals who are using insurance (private or public) because the payment rates are so low; thus, they only provide such services to individuals who can pay cash. This phenomenon is particularly problematic for the public system (e.g., Medicaid), since individuals who receive such coverage are from lower socio-economic backgrounds and/or are racial/ethnic minorities who often encounter significant barriers to obtaining necessary care. If these payment policies and practices continue, the disparities between individuals who can and cannot afford mental health services will continue to grow. The specific quality aims affected by these funding barriers include patient-centered and efficient services, and timely and equitable care.

Another major problem with the current behavioral health care system is that it is fragmented and, in many geographical areas, in utter disarray. Behavioral health services are often provided in multiple settings, requiring consumers to travel from location to location to receive all the care necessary for a given problem. Individuals from lower socio-economic backgrounds, who often do not have adequate transportation to get to these different appointments at multiple locations, are greatly affected by this problem. Similar problems exist in rural regions, where individuals often are required to travel many miles to access appropriate behavioral health care. The lack of a continuum of care that provides for adequate transitions from one level of service to another, or that includes all ancillary or adjunct services, is another way this fragmentation is demonstrated. Social workers witness these phenomena daily, and often are required to spend a great deal of time, energy, and resources to solve these issues for consumers of behavioral health services. Service fragmentation relates to the following quality aims of timely services; effective, efficient care; and equitable care.

The need for equitable care within the behavioral health care system was well documented by a 2001 report from the U.S. Surgeon General. The report states that racial/ethnic minorities bear a disproportionate level of disability from mental health disorders in this country. Historically, these populations have been underserved or poorly served by the mental health care system. Recent studies indicate that disparities exist in the receipt and quality of behavioral health care between racial/ethnic minorities and Caucasians. Additional studies indicate that when racial/ethnic minorities do access services they do so in the public system. While these issues are primarily focused on the aim of “equitable” care as defined by the IOM, other quality aims that are impacted include patient-centered, efficient, and timely care.

Ensuring that behavioral health care is safe for individuals receiving services is another concern of the social work profession. The use of seclusion and restraint within the mental health service delivery system is no longer acceptable. Recent estimates indicate that 150 deaths per annum across the nation are due to such practices; children are at particularly high risk for death and serious injury. Furthermore, the use of seclusion and restraint varies dramatically from facility to facility, and the level of knowledge of how to prevent and avoid such use is varied.

During the testimony of the Alliance of Mental Health Professions on April 26 th , data was presented indicating that significant segments of the mental health workforce are aging and not being replaced. This information was previously provided to this committee, and will be included in an upcoming report from the Center for Mental Health Services (CMHS). It must be noted that the data in the CMHS report reflects only the membership of the provider associations involved in the development of the document, and not the entire behavioral health field. This aging of the workforce is represented in each of the behavioral health professions, and will ultimately lead to a severe shortage in the next decade. Furthermore, it is clear that this work force is primarily Caucasian, which is discrepant from the populations receiving services or those in need of services.

This raises questions about the cultural competence and relevance of the current work force. Since the work force received training many years ago, the interventions being employed are often based on theory and practices that were taught at the time. There exists a need to provide up-to-date training on behavioral health care practices and core competencies to decrease the timeline from science to services. Data from a recent survey indicates that many within the social work profession (and other behavioral health professions) desire additional training in certain fields of practice to improve their skills and meet the needs of the client population. 4 The training issues presented herein relate to the IOM aims of effective and efficient care as well as patient-centered services.

2. What strategies should be employed to improve these defects in behavioral health care quality?

The funding barriers that were discussed in the previous section are creating a variety of problems within the behavioral health care system—negatively impacting use of effective interventions, the ability to provide patient-centered services, and resulting in care being provided in an inefficient and untimely manner. The ability to provide comprehensive services and a continuum of care to individuals is also affected by many of the funding issues discussed. Specific recommendations include:

• Eliminate discriminatory behavioral health coverage limits by insurers/payors;
• Increase provider payment rates for services;
• Lift the barriers that prevent the funding for EBPs;
• Change the policies that allow for funding of ineffective interventions; and
• Increase or improve the funding of services to create a system that is not fragmented and supports continuums of care.

Both the IOM and NFC reports indicate the importance of providing care that is based on research. According to the IOM report, it takes between 15 and 20 years from the discovery of effective forms of treatment to their incorporation into routine care. The need to ensure that evidence-based practices (EBPs) are developed and implemented at a faster rate is imperative, and NASW fully supports any efforts to continue in this direction. While many of the accepted practices appear effective, insufficient research has been completed to demonstrate the value of such interventions. In addition, promising practices that have been created in the field may be in existence for many years before a body of research is developed showing effectiveness. To help ensure that behavioral health research is relevant, NASW recommends the following:

• Increase the involvement of providers and provider associations in the development of a structured practice research agenda;
• Ensure and increase the involvement of consumers and families in the development of this research agenda;
• Improve the science to service time lag, and focus on a “services to science” approach; and
• Increase funding and support services research and research that transcends traditional clinical trials.

The behavioral health workforce consists of different professions, with differences in training both across and between disciplines. Current training practices need to become more effective and efficient, and models of training from other fields should be explored. A set of core competencies for the behavioral health field needs to be developed and regularly updated, and training of these competencies should be a priority. In addition, providers should be trained in, and be proficient in, competencies that are relevant to specific populations being served. In order to ensure that continued competence is achieved, the credentialing and licensing process should be improved.

3. What issues should the IOM Committee assure receive priority attention in its study?

In order to gain a better understanding of the behavioral health field, an important first step would be to conduct a national survey of the workforce. This would provide data about the various professions and the availability of providers throughout the country. Such a survey should include information on demographics, education and training (including continuing education), practice patterns and services provided, and populations served. Gaining a better understanding of the entire workforce will result in being able to identify and improve any deficiencies within the current provider population, as well as identify potential future deficiencies. Information collected from such a survey would also potentially help identify core competencies for this field and other training needs.

Training or re-training the current work force should be a priority, focusing on providing opportunities for professionals to increase and/or improve their skills. The IOM should make strong recommendations for such training, which could be implemented and funded by the appropriate entities. Providing training or re-training to the work force could lead to services that are more effective and efficient, and potentially improve the cultural relevance of behavioral health care. In addition, providing more financial resources to hire and retain behavioral health professionals should be considered. Increasing the salaries of providers in geographical areas (e.g., rural) that historically have staffing difficulties should be considered. Furthermore, entry-level salaries in all settings should be increased, which would attract younger people to enter this field in larger numbers.

Conclusion

NASW supports the many recommendations outlined in the Commission's report, and we particularly applaud their strong emphasis on the concept of “recovery” for individuals receiving mental health services. This focus is, without doubt, one of the most courageous steps taken by this, or any other, Commission in recent history. While many may see this goal—mental health care that is consumer and family driven—primarily as a way to involve consumers and family members in the treatment process, it is just as important to include these individuals in efforts to transform the current system. Social workers provide a great deal of support to consumers, so they may become more effective advocates in this arena. NASW encourages this committee, and any future groups, to continue focusing on “recovery” as an underlying principle to mental health care.

The National Association of Social Workers wishes to thank the IOM Committee for the opportunity to present our views on this important matter. Please let NASW know if you require additional information or further support from our organization.

References:

New Freedom Commission on Mental Health. (2003). Achieving the promise: Transforming mental health care in America (Final Report) . (DHHS Pub. No. SMA-03-3832). Rockville, MD: Substance Abuse and Mental Health Services Administration.

United States Public Health Service, Office of the Surgeon General. (2001). Mental health: Culture, race, and ethnicity (A supplement to mental health: A report of the Surgeon General). Rockville, MD: Author.

Algeria, M., Perez, D. J., & Williams, S. (2003). The role of public policies in reducing mental health status disparities for people of color. Health Affairs, V22, No5 (pp. 51–64).

National Association of Social Workers. (2004). Practice Services Network, Survey III (Final Report). (Available from NASW, 750 First Street, NE, Suite 700, Washington, DC 20002.)

United States Department of Health and Human Services. (In Publication). Mental health United States, 2002. Rockville, MD: Author.

Institute of Medicine Committee on Quality of Health Care in America. (2001). Crossing the quality chasm: A new health system for the 21 st century. Washington, DC: National Academies Press.