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Welcome and
Conference Introduction
Reforming the health care system from a mental health and economic perspective: a few thoughts
Eric Latimer, Ph.D.Research ScientistDouglas InstituteAssociate Professor/Associate MemberDepartments of Psychiatry/Epidemiology, Biostatistics and Occupational Health
CHSP Annual conferenceMarch 21 2012
Outline
1• Three aspects of a health care system
2 • The importance of mental illness
3• Learning from other countries: Evidence-based practices
(EBPs)
4• Too much spending on meds, not enough on EBPs
5• What to do?
Taxes
Insurance premiums
Out-of-pocket payments
CSSSs
MDs
Hospitals
Meds
Other providers
Community orgs
Care and social services provided to patients(PHYSICAL & MENTAL HEALTH, + PSYCHO-SOCIAL SERVICES)
FINANCING ALLOCATION DELIVERY
$
Three aspects of a health care system*
* Note that this graph does not reflect all possible sources of funds or providers
Tax revenues
Private insurers
Out-of-pocket
CSSSs
MDs
Hospitals
Meds
Other providers
Community orgs
Care and social services provided to patients(PHYSICAL & MENTAL HEALTH, + PSYCHO-SOCIAL SERVICES)
FINANCING ALLOCATION DELIVERY
$
Three aspects of a health care system
Tax revenues
Private insurers
Out-of-pocket
CSSSs
MDs
Hospitals
Meds
Other providers
Community orgs
Care and social services provided to patients(PHYSICAL & MENTAL HEALTH, + PSYCHO-SOCIAL SERVICES)
FINANCING ALLOCATION DELIVERY
$
Three aspects of a health care system
Why care about the granularity of services for a specific group of conditions in considering health policy?
• Specificities of different health conditions• For a system overall to be effective and cost-
effective, attention must be paid to each component part– Whole greater than sum of its parts
Unipolar depressive disorder 3rd most important cause of global of disease overall
4.3% of all DALYs
Source : WHO, hwww.who.int/healthinfo/global_burden_disease/en/index.html
Alcohol use disorder in 17th place; self-inflicted injuries in 20th
1.6%
1.3%
Leading causes of disease burden for women aged 15–44 years, high-income countries, and low-
and middle-income countries, 2004: Schizophrenia, bipolar disorder (and PTSD) rise in importance
Source : WHO, hwww.who.int/healthinfo/global_burden_disease/en/index.html
Lim et al. (2008) estimate total economic burden of mental illness in Canada at $50.8 billion in 2003
Source: Lim et al. (2008), A new population-based measure of the burden of mental illness in Canada, Chronic diseases in Canada, 28(3).
Using more comprehensive methods Jacobs et al. (2010) arrive at a higher figure for direct
medical costs than Lim et al. (2008)…
Source: Lim et al. (2008), A new population-based measure of the burden of mental illness in Canada, Chronic diseases in Canada, 28(3).
…namely, $14.3 billion…or about 7.2% of total health expenditures
Inpatient
Physicians
Community and social
Pharma-ceuticals
Public income supports
Other services
Of this, people with severe mental illness, though fewer (2-3% vs. perhaps 20% overall*) account for a large share
Cost Category Estimated Cost – Schizophrenia alone
(billion CAN $)Direct (HC & more) 2.02
Productivity losses 4.83
Total 6.85
Source: Goeree et al., “The Economic Burden of Schizophrenia in Canada in 2004”, Curr Med Res Opin. 2005;21(12):2017-2028* Variable depending on what is counted
To sum up…
• Large relative disability burden of mental illness, especially considering adults at key productive ages
• Significant costs of treating mental illness
Learning from other countries: Evidence-based practices for people with severe mental illness
• Normally defined on the basis of 2 or more successful RCTs
• Lists vary according to interpretation of evidence• Model fidelity becomes an issue – higher fidelity,
better outcomes– Concerns with implementation
• Typically involve organization of professionals around pursuit of a goal for clients – overall support of people with SMI, employment, housing, optimal use of medications, limit harm from substance abuse…
Evidence-based practices for people with severe mental illness: Examples
• Assertive Community Treatment• Early Intervention Services for Psychosis• Family Psychoeducation• Integrated Tx for dual disorders (MI +
substance abuse)• Supported employment• Housing First• Illness Management and Recovery
Common characteristics of EBPs
• Aim for community integration and social inclusion• Break down the silos: Close integration between
treatment and rehabilitation (e.g., alcohol, employment, housing)
• Draw out and build on client goals and strengths as well as resources in natural environments
• Real-time adjustability to changes in patient needs
• …as may be seen, commonalities (e.g. breaking down silos) but also specificities compared to other forms of care
Learning from other countries: Implementing EBPs
• "Spray and pray" does not work– Coaching essential
• Technical assistance centers– CNESM in Québec– Monitoring fidelity and outcomes
Now for a concern related to allocation
Contrast: Lack of funding for EBPs, essentially unlimited funding for medications
• Closed funding envelopes for psychosocial care in regions perceived as being disproportionately rich (e.g., Montreal)– Result: Difficult to fund even transitions from less
to more effective services• Physicians can prescribe whatever they want,
including off-label, with very few constraints
Potential savings from psychiatric drugs
• Possibility of increasing efficiency via more sparing use of psychotropic medications– 2.8 billion $ on psychotropic meds in Canada
2007/2008– About 629 million $ on antipsychotics in 2007
• Data suggest large variation in propensity to prescribe high doses of antipsychotics across prescribers, to patients with schizophrenia
Large variability in % patients with schizophrenia on high doses of antipsychotics, Québec, 2004
0.2
.4.6
.8P
ropo
rtio
n o
f ph
ysic
ian'
s pa
tien
ts o
n hi
gh d
ose
Small Medium Large
Physician's patients on high dose (>=2 mo.) stratified by number of patients
Observed AdjustedSource: Latimer E, Wynant W, Naidu A, Clark R, Malla A, Moodie E, Tamblyn R. Manuscript in preparation
Potential savings from psychotropic medications (2)
• Studies assembled by Whitaker (2010) suggest overconsumption of psychiatric medications, leading in a significant number of cases to chronicisation (very costly and not supportive of recovery!)
• Non-optimality of barely constraining expenditures on meds while severely constraining expenditures on psychosocial services
One way of viewing the problem…
• A mechanism for trading-off relative benefits of spending on one type of program or service vs another seems needed
• CSSSs were supposed to have responsibility for the population on their territory; but currently they cannot.– Hospitals, MDs, medication spending, not under
their control
A British-style way forward?
• A single authority (CSSS?) could keep track of overall outcomes for a population, and purchase services (physicians, hospitals) and medications for this population
• Introduce incentives for increasing process quality, effectiveness and cost-effectiveness– Requires measuring them!
• Such an approach should increase access to well-implemented EBPs for people with severe mental illness – among other benefits
More realistically…
• …however, probably politically impossible in Québec!
• In its absence, prospect of slow incremental change, mostly through persuasion, and collaborative arrangements
