How Health Care Reform Is Like a High School Lunchroom

What does the new healthcare environment have in common with a high school lunchroom? Many Behavioral Healthcare providers have been experiencing high levels of anxiety as they hear and read disconnected snippets–or long lectures–about all the fundamental ways their work, organizations, and very lives are about to transform. “It’s all going to change,” and “Hospitals are going to be our payors now,” and “Health Homes/HIEs/RHIOs/ACA/ACOs are going to put us out of business,” and on and on. There’s enough hysteria to go around these days, and apart from its impact on our own mental health, it’s worth pulling apart some of these strands to see what we’re really talking about.

The big question we’ve been talking about for decades in our field is how we can use our resources to drive outcomes more efficiently. Today, in all likelihood, you provide services in a particular modality using a combination of funding streams. Probably most of your revenue ultimately comes from Medicaid or Medicare, and probably you are being paid on a fee-for-service basis. Additionally, it’s safe to assume that for most of the time you’ve been in this field, you’ve been working to make the work you do ever more efficient and effective. You’ve been trying to get more bang for the buck, and generally, trying to do more with less. For the most part, you’ve thought of your organization as a self-contained unit; sure, you get referrals from other organizations and sure, you’re a big part of the communities in which you work. But generally, this conversation has been about how your organization can drive outcomes more efficiently to sustain itself.

It’s your context that’s changing. Almost all the new ideas, projects, experimental payment structures, and acronyms are built around the idea that providing real care for people who don’t have the resources to pay for care themselves is going to require multiple specialized providers–the entire community—working together. It’s the community that will be providing care now, not the individual organization. It’s you—and the hospital, the shelter down the street, the DD organization across town—everyone. That is why you are suddenly feeling like you need to care about what your local hospital is doing and how it will affect you. That is why this process feels like finding a seat to eat your lunch on the first day of high school. You don’t know the angles, don’t know who your friends are, and don’t know who’s nice and who’s a bully. You are now part of a web of organizations that offer a wide range of health care services to a particular population, and you are going to need to figure out how to work in that context.

The truth, though, is that while it would be silly to ignore everything that’s happening, this is less about changing how you operate than it is about changing how you relate to other service providers. There has been much talk about Primary Care’s “integration” with Behavioral Care, but no one that I’ve spoken to thinks of this as a real organizational, physical integration. Rather, it is a data integration that allows each provider, be it primary or behavioral care, to leverage the information being collected by all the other providers in a person’s life. At Foothold, we’ve been working steadily to provide a range of tools that will enable you to do two broad but crucial things: 1) share clinical data safely and in real time with other providers in your community, and 2) tell your story with solid support from the objective clinical data in your EHR. These two “new” ideas comprise the vast majority of the changes that are currently coming at you. In both cases, they are about finding a way for you to be financially sustainable and to become a crucial part of the care network in your community. In both cases, they will enable us to address the fundamental challenge posed by the small number of dual or multi-diagnosis individuals who utilize a vastly disproportionate percentage of the monies available for care.  

Put bluntly, keeping Behavioral Healthcare recipients out of the ER when they would be better served by calling or visiting you is the key, the lynchpin, to all the health care reform that comprises our current national conversation. By finding an EHR provider that enables you to share data with your local hospital and other BH care providers, and enables you to tell powerful stories about the value you bring to your local community and this larger national conversation, you will have done nearly all you need to do to survive and thrive in our new world.