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Welcome and Conference Introduction

Welcome and Conference Introduction. Reforming the health care system from a mental health and economic perspective: a few thoughts. Eric Latimer, Ph.D . Research Scientist Douglas Institute Associate Professor /Associate Member Departments of Psychiatry/

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Welcome and Conference Introduction

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  1. Welcome and Conference Introduction

  2. Reforming the health care system from a mental health and economic perspective: a few thoughts Eric Latimer, Ph.D. Research Scientist Douglas Institute Associate Professor/Associate Member Departments of Psychiatry/ Epidemiology, Biostatistics and Occupational Health CHSP Annualconference March 21 2012

  3. Outline

  4. Three aspects of a health care system* Communityorgs CSSSs Care and social services provided to patients (PHYSICAL & MENTAL HEALTH, + PSYCHO-SOCIAL SERVICES) Taxes Hospitals MDs $ Meds Insurance premiums Other providers Out-of-pocketpayments ALLOCATION DELIVERY FINANCING * Note thatthis graph does not reflect all possible sources of fundsor providers

  5. Three aspects of a health care system Communityorgs CSSSs Care and social services provided to patients (PHYSICAL & MENTAL HEALTH, + PSYCHO-SOCIAL SERVICES) Tax revenues Hospitals MDs $ Meds Privateinsurers Other providers Out-of-pocket ALLOCATION DELIVERY FINANCING

  6. Three aspects of a health care system Communityorgs CSSSs Care and social services provided to patients (PHYSICAL & MENTAL HEALTH, + PSYCHO-SOCIAL SERVICES) Tax revenues Hospitals MDs $ Meds Privateinsurers Other providers Out-of-pocket ALLOCATION DELIVERY FINANCING

  7. 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

  8. Unipolardepressivedisorder 3rd most important cause of global of diseaseoverall 4.3% of all DALYs Source : WHO, hwww.who.int/healthinfo/global_burden_disease/en/index.html

  9. Alcohol use disorder in 17th place; self-inflicted injuries in 20th 1.6% 1.3%

  10. 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

  11. Lim et al. (2008) estimate total economicburden of mental illness in Canada at $50.8 billion in 2003 Source: Lim et al. (2008), A new population-basedmeasure of the burden of mental illness in Canada, Chronicdiseases in Canada, 28(3).

  12. Using more comprehensivemethods Jacobs et al. (2010) arrive at a higher figure for direct medicalcoststhan Lim et al. (2008)… Source: Lim et al. (2008), A new population-basedmeasure of the burden of mental illness in Canada, Chronicdiseases in Canada, 28(3).

  13. …namely, $14.3 billion…or about 7.2% of total healthexpenditures Public income supports Inpatient Physicians Other services Pharma-ceuticals Community and social

  14. Of this, people withsevere mental illness, thoughfewer (2-3% vs. perhaps 20% overall*) account for a large share Source: Goeree et al., “The Economic Burden of Schizophrenia in Canada in 2004”, Curr Med ResOpin. 2005;21(12):2017-2028 * Variable depending on what is counted

  15. To sum up… • Large relative disability burden of mental illness, especially considering adults at key productive ages • Significant costs of treating mental illness

  16. 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…

  17. 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

  18. Common characteristics of EBPs • Aim for communityintegration and social inclusion • Break down the silos: Close integrationbetweentreatment and rehabilitation (e.g., alcohol, employment, housing) • Draw out and build on client goals and strengths as well as resources in naturalenvironments • Real-time adjustability to changes in patient needs • …as maybeseen, commonalities (e.g. breaking down silos) but alsospecificitiescompared to otherforms of care

  19. Learning fromother countries: ImplementingEBPs • "Spray and pray" does not work • Coaching essential • Technical assistance centers • CNESM in Québec • Monitoring fidelity and outcomes

  20. Now for a concernrelated to allocation

  21. Contrast: Lack of funding for EBPs, essentiallyunlimitedfunding for medications • Closedfundingenvelopes for psychosocial care in regionsperceived as beingdisproportionatelyrich (e.g., Montreal) • Result: Difficult to fundeven transitions fromless to more effective services • Physicianscanprescribewhatevertheywant, including off-label, withvery few constraints

  22. Potentialsavingsfrompsychiatricdrugs • Possibility of increasingefficiency via more sparing use of psychotropicmedications • 2.8 billion $ on psychotropicmeds in Canada 2007/2008 • About 629 million $ on antipsychotics in 2007 • Data suggest large variation in propensity to prescribehigh doses of antipsychoticsacrossprescribers, to patients withschizophrenia

  23. Large variability in % patients withschizophrenia on high doses of antipsychotics, Québec, 2004 Source: Latimer E, Wynant W, Naidu A, Clark R, Malla A, Moodie E, Tamblyn R. Manuscript in preparation

  24. Potentialsavingsfrompsychotropicmedications (2) • Studies assembled by Whitaker (2010) suggestoverconsumption of psychiatricmedications, leading in a significantnumber of cases to chronicisation (verycostly and not supportive of recovery!) • Non-optimality of barelyconstrainingexpenditures on medswhileseverelyconstrainingexpenditures on psychosocial services

  25. One way of viewing the problem… • A mechanism for trading-off relative benefits of spending on one type of program or service vs anotherseemsneeded • CSSSsweresupposed to have responsibility for the population on theirterritory; but currentlytheycannot. • Hospitals, MDs, medicationspending, not undertheir control

  26. A British-style wayforward? • A single authority (CSSS?) couldkeeptrack of overalloutcomes for a population, and purchase services (physicians, hospitals) and medications for this population • Introduceincentives for increasingprocessquality, effectiveness and cost-effectiveness • Requiresmeasuringthem! • Such an approachshouldincreaseaccess to well-implementedEBPs for people withsevere mental illness – amongotherbenefits

  27. More realistically… • …however, probablypolitically impossible in Québec! • In its absence, prospect of slow incremental change, mostlythrough persuasion, and collaborative arrangements

  28. Thankyou for your attention eric.latimer@mcgill.ca

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