Are Healthcare Leaders Ready for the RealRevolution?

Linda Rosenberg, MSW

Abstract

The current revolution, that could pass us by if we are not prepared to join it, is a consumer-directed,technologically driven revolution in the way we receive, process, and use information. Today, theknowledge we need—as business owners, healthcare consumers, and informed citizens—is literally inthe palm of our hands. The future has arrived and we cannot be late to the dance. Citizen science,integration, and data-driven care will shape our future. Healthcare leaders must be comfortable withcomplexity and eager to embrace fast-paced, revolutionary changes. We must be prepared to lead inintegrated health care environments that harness technology and value data.

We are living in the midst of a revolution. But contrary to what we think and how it sometimesfeels, it is not a health care revolution.

Health care is changing because health care has always changed. Modern sanitation and thediscovery of antibiotics changed health care. The development of high tech imaging techniqueschanged health care. The understanding that even individuals with the most serious mental andsubstance use conditions can and do walk the recovery path, changed health care.

The current revolution, that could pass us by if we are not prepared to join it, is a consumer-directed, technologically driven revolution in the way we receive, process, and use information.Today, the knowledge we need, as business owners, health care consumers, and informed citizens,is literally in the palm of our hands.

The future has arrived and we cannot be late to the dance. We have to get off the sidelines andimmerse ourselves in this brave new world. But here is the good news: We are just in time.

In our imagined future, what does health care look like? Clearly, there are a number of forcesoutside our control that will affect the form and function of the American health care system. Howwill the Supreme Court decide the issues before them, including the constitutionality of theindividual mandate and the Medicaid expansion? Will Congress live with the extensive cutsresulting from the failure of the super committee to curb spending? What shape will entitlementreform take? The only constant is change.

No matter what the Supreme Court decides, no matter who wins the Presidential andCongressional Elections this year, change will continue. Action on Social Security, Medicare,and Medicaid is likely to unfold quickly in 2013. The growth of traditional models of managed

Address correspondence to Linda Rosenberg, MSW, National Council for Community Behavioral Healthcare, Rockville,MD, USA. Email: MeenaD@thenationalcouncil.org.

Journal of Behavioral Health Services & Research, 2012. 215–219. c) 2012 National Council for Community BehavioralHealthcare.

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behavioral health will continue. Payers, including state Medicaid authorities, are straining tocontrol costs and are increasing their use of risk-based managed behavioral health models. Thepotential growth of Medicaid enrollment in 2014 is only fueling the flight of states into managedcare.

At the same time, health care is marching quickly to the expectation that a single organization, ahospital that transformed itself into an accountable care organization, or a health or behavioralhealth center that is grown into a health home, will manage the total care and total costs of apopulation. Endorsement of bundled payments as a quality improvement and cost–savingstechnique will continue, and the role of care management for costly chronic conditions, includingbehavioral health, will be the focus of services delivery.

The approach of hot spotting, using medical billing data to locate hot spots of high-costpatients down to the city block, is gaining traction. These high utilizers repeatedly accesshospitals and emergency rooms and have complex conditions compounded by diverse socialissues. By coordinating their care in the community, costs of care can be brought downsignificantly.

Dollars continue to shift from hospitals to community-based care, from specialists to primarycare, from physicians and nurses to technicians and community workers, and from services totechnologies. Consumer engagement, not compliance, is the key competency and treatment ondemand; when, where, and how the consumer requests it will become the norm. Purchasers areheating up the call for publicly available process and outcome data.

What does this mean for us as health care leaders? It means we must be passionately curiousabout the world around us. We must be alert, awake, and engaged. We need to remain committed toour core vision but flexible in how we achieve it. We need to understand, learn, and implement newmodels of financing, services delivery, and performance measurement all at the same time. Threeelements will shape our future.

Citizen Science

First and foremost, health care will be led by citizen science. This is the Facebookgeneration: individuals want to educate themselves. They are motivated consumers in thetruest sense of that word. Eight in ten internet users look online for health information,making it the third most popular online pursuit following email and using a search engine.1

Browse through the health and medicine section of your phone’s App store. You will find allsorts of free or inexpensive Apps to help you sleep better, quit smoking, abstain fromalcohol, and relieve stress.

Increasingly, self-diagnostics, self-monitoring, and self-medication will be aided by the use ofsmartphone technology. We can monitor blood pressure, calorie intake, and mood on the samedevice that allows us to call for takeout or play Words with Friends. We will be using biomarkers toprevent disease, injectable cameras to diagnose disease, and virtual reality systems to treat disease.This is not science fiction. This is now!

In Colorado, there is a person who is deaf and recovering from drug and alcohol abuse incourt-ordered counseling with Arapahoe House.2 The individual is equipped with asmartphone.

Other applications on the phone provide a panic button with direct access to the individual’scounselor. If the local adviser is not available, the individual can link through a video signlanguage translator to other trusted friends. Another button offers motivational videos, and stillanother links to a Facebook-style chat with other hearing-impaired clients supporting one anotherin recovery.

Another example is Health Buddy,3 an easy-to-use computer that entertains you with gameswhile asking questions about your health and well-being. It encourages medication adherence and

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lifestyle changes, and it is available in your home, day and night. Information entered into HealthBuddy is transmitted to a data center where practitioners monitor individuals with chronicconditions, including mental illness, and flag those who need an inperson intervention.

Think about what this means. This means we can virtually engage, monitor, and support peoplein managing their own health. It means we can free up practitioners to focus on those who requireintensive inperson attention. This is a revolution driven by technological innovation that ischanging health care expectations.

What does this mean for us as health care leaders? It means we need to become the masters ofour digital universe. Today, we send 144.8 billion emails4 and 4.1 billion texts5 each and every day.In health care, secure email is replacing physician office visits. Social networking sites such asTwitter, Facebook, and LinkedIn are being used for recruiting staff, market research, and customerservice. These sites are no longer limited to the young: It has become a job requirement that youknow how to make the best and most profitable use of these tools. Twenty-first century health carewill be citizen-directed care.

Integration

Health care will become increasingly integrated with treatment viewed as a single function thatincludes both physical and mental health. Individuals with serious mental illnesses are dying fromheart disease, lung disease, and cancer in their mid-50s, decades earlier than the general population.Primary care physicians are treating people with mental illnesses and addictions, and they need ourhelp.

We need to step out of our silos and work across health care sectors. Those who embrace trueintegration at every level- from policy, to plan, to practice- are the ones who will succeed.

We are seeing the health management of populations divide into two groups: the 5% withmultiple chronic conditions, and the 95% with less complex conditions.6 For the 95%, this meansonline services and primary care-focused medical homes. For the high-cost 5% of the population,including dual eligibles, this means expanding their management to include overall wellness:Providing social supports and teaching self-management in addition to caring for their chronicphysical and mental health problems.

What does this mean for us as health care leaders? It means opportunity, the opportunity to helpprimary care professionals identify and treat people with mental illnesses and addictions in theirsettings; the opportunity to assume responsibility for the whole health of people with seriousmental and addiction disorders; and the opportunity to care and manage high-need, high-costpopulations for both public and commercial payers across settings.

It means we need cross-cultural communication skills. For the 21st Century behavioral healthcare leaders, the concept of cross-cultural communication is not about learning a new language. Itis about the ability to be authentic in unfamiliar situations, and it will have an impact on our bottomline. Think about the uncomfortable, anxious, and angry executive teams in our industry who arebeing asked, in the new norm of the health environment, to move to productivity-basedcompensation, to work in a general medical practice, to care manage a caseload of people withdiabetes, and to use a registry to enter blood pressure.

Or think about a community-based behavioral health chief executive officer (CEO) not justcontinuing to meet monthly with the other behavioral health CEOs operating in her state, but alsomeeting and working with ambulatory medical practice leaders and hospital CEOs. That CEOneeds to ensure that the electronic health record her organization is buying can communicate withother behavioral health organizations in her state, but also to the rest of the healthcare providers inher community. Integration is not a concept; it is a way of doing business. Our goal is forindividuals with mental and substance use disorders to recover and lead healthy, full, and

Are Healthcare Leaders Ready for the Real Revolution? ROSENBERG 217

productive lives. This goal does not change; we just need to talk a different language withunfamiliar colleagues.

Data

Finally, health care of the future will be data driven. Healthcare increasingly transparent and theresults, increasingly public. Every federal agency involved in paying for health care, the Centersfor Medicare and Medicaid Services, the Health Resources Services Administration, the SubstanceAbuse and Mental Health Services Administration, and every national standard-setting andaccrediting body, including the Joint Commission and National Committee for Quality Assurance,is working on behavioral health performance indicators and outcome measures.

In February 2012, Medicaid proposed seven new HEDIS care management measures7 forschizophrenia and bipolar disorder. New measures focused on quality care management for peoplewith serious mental illness who are at greater risk for morbidity and mortality. These are measuresthat organizations will be expected to report. Performance anonymity will not last: We have toshow results.

Not all results will be positive. Our treatments are limited in their effects, and recovery is astruggle. But if we do not keep score, we will never know if we are winning the game. If we do notmeasure it, we cannot manage it or improve it, and in the future we will not be paid for it.

We are depending upon health information technology (IT) for the real-time data that supportspublicly shared performance measurement, information that can help people recover, demonstrateefficacy, and trim costs. Tom Daschle, former US Senate majority leader and a key architect ofPresident Obama’s health care plan, believes health IT is transformational.8 As Senator Daschlepoints out, we have a 21st Century operating room and a 19th Century administrative room; it is stillover 80% paper driven.8 This leads to inefficiencies, mistakes, and, ultimately, higher costs.

Health IT can help us prevent medical errors, facilitate repetitive paperwork, and addresscoordination of care among health sectors. But health IT requires more than an electronic healthrecord; it requires registries, reminder systems, health information exchange alternatives, consumerportals, claims and clinical data warehouses, and episode of care analysis.

When we use data to help us make decisions about what services to provide, we avoid shoot-from-the-hip mistakes. We know our costs, and we say no to reimbursement rates that areinadequate. Whether performance is tied to compensation or not, openly shared knowledge of one’sperformance, and the performance of others, is a key to improving performance.

What does this mean for us as health care leaders? It means preparing for financial change,embracing new service delivery models, and implementing metrics-based managementsystems that give us the data we need to make the tough decisions. It means we need tobe comfortable with uncertainty and complexity. We have to be comfortable setting offwithout a map or compass, or without Siri to guide us. We have to be comfortable withmaking discomfort our comfort zone.

We live in a world where we are faced with increasing distractions. We spend too much timereceiving such as email, telephone, text messages, documents to review, spreadsheets to analyze,planned meetings, and unplanned meetings. Sometimes we just want to shut the door and get ourwork done! But this is our work. When we think we are multitasking, we are actually multi-inspiring, increasing our motivation to learn and solve problems. We are operating as systemthinkers: People who can see the connections between ideas, issues, and initiatives. We tune intothe world around us, and we seize opportunity in whatever guise it appears.

The future has arrived and we are part of it. Are we prepared to be innovative, gutsy leaders?Are we comfortable with complexity and eager to embrace fast-paced, revolutionary changes? Arewe prepared to lead in integrated health care environments that harness technology and value data?

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Even as we look to the future and as the US Healthcare Systems embark on an era of dramaticchange in the way services are delivered, community mental health and addictions providers arestruggling against antiquated payment and regulatory structures. To support the benefits that mentalhealth and addiction treatment services bring to health care systems, the National Council forCommunity Behavioral Healthcare and our 2,000 member organizations seek congressionalsupport for a new federal definition and standards for Federally Qualified Behavioral HealthCenters (FQBHCs). These entities would receive reimbursement for the costs of providing servicesand have the ability to invest in new service delivery models and improve practice while meetingclearly defined national standards and oversight. It is time for fairness and parity for communitybehavioral health organizations, practitioners, and consumers. Creation of a federal status forFQBHCs will build a bridge to the future, a world where care can be better coordinated amonghealth care agencies and where consumers benefit from better treatment services and health.

We are embracing new technology, service delivery models, and payment mechanisms. We aredoing the right thing by the millions of individuals in this country with behavioral health disorderswho want to do more than survive: They want to thrive in their homes, in their jobs, and in theircommunities. They deserve nothing less.

References

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2. Booth M. GPS helping substance abuser find his way to sobriety. The Denver Post Thursday, April 26, 2012. Available online at: http://www.denverpost.com/news/ci_19597664. Accessed on April 25, 2012.

3. Health Buddy System. Available online at: http://www.bosch-telehealth.com/en/us/products/health_buddy/health_buddy.html. Accessed onApril 25, 2012.

4. Radicati S, Hoang Q. Email Statistics Report, 2012–2016. Available online at: http://www.radicati.com/wp/wp-content/uploads/2012/04/Email-Statistics-Report-2012-2016-Executive-Summary.pdf. Accessed on April 25, 2012.

5. CTIA, The Wireless Association® Announces Semi-Annual Wireless Industry Survey Results. Available online at: http://www.ctia.org/media/press/body.cfm/prid/1870. Accessed on April 25, 2012.

6. The Marketing Challenge of The 5 % & The 95 %. OPEN MINDS Available online at http://www.openminds.com/market-intelligence/basic/020112a.htm. Accessed on April 25, 2012.

7. Recommendations for Health Insurance Exchange Quality Measure Requirements, NCQA, Available online at: http://www.ncqa.org/LinkClick.aspx?fileticket=qf3CpGcEPXA%3D&tabid=1425&mid=5897&forcedownload=true. Accessed on April 25, 2012.

8. Daschle T. 70 Yards to the Health Reform Touchdown. National Council Magazine 2012; 1:10–12. Available online at: http://www.thenationalcouncil.org/galleries/NCMagazinegallery/12_NCCBH%20magazine%231_web.pdf. Accessed on April 25, 2012.

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