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. |
