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Report of the Presidents New Freedom Commission on Mental Health
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Statement of
Howard H. Goldman, M.D., Ph.D.
Professor of Psychiatry
Director of Mental Health Policy Studies
University of Maryland
Baltimore, Maryland
Regarding
Performance and Outcome Measurement in Substance Abuse and Mental Health Programs
Before The
Subcommittee on Substance Abuse and Mental Health Services
Committee On
Health, Education, Labor and Pensions
United States Senate
July 20, 2004
Mr. Chairman, Senator Kennedy, and Members of the Subcommittee:
Good morning Mr. Chairman, Senator Kennedy, and Members of the Subcommittee.
My name is Howard Goldman. I am a psychiatrist and mental health services researcher
at the University of Maryland School of Medicine and served as the senior scientific
editor of the Surgeon General’s 1999 Report on Mental Health and as a
consultant to the President’s New Freedom Commission on Mental Health.
I am honored to participate in today’s hearing and am proud to be doing
so on behalf of the Campaign for Mental Health Reform.
Our Campaign, galvanized by the call of the President’s New Freedom
Commission on Mental Health to transform mental health care in America, was
created to serve as the mental health community’s united voice in promoting
federal policy changes that will transform mental health care from a fragmented,
unresponsive, and inefficiently funded delivery system to one that meets the
needs of services users and their families, is integrated across programs,
and is adequately and responsibly funded.
I am pleased to respond to your invitation to discuss what we have learned
about performance and outcomes in mental health services and our capacity to
measure effectiveness of programs from multiple perspectives. I will review
what we know about this important topic and its implications for mental health
policy generally and for the federal role and SAMHSA leadership in particular.
My comments will draw upon current research and numerous publications, as well
as two reports of the Surgeon General and the reports of the President’s
New Freedom Commission on Mental Health.
In the course of a year, about one in five persons has a diagnosable mental
disorder, excluding substance use disorders. Almost everyone’s life has
been touched in some way by mental illness – if not due to one’s
own impairment, then in caring for family members, close friends, or colleagues.
Unfortunately, notwithstanding the existence of effective treatments and services
and the real prospect for recovery, the majority of individuals who have a
diagnosable disorder do not seek or find the help they need. This personal
tragedy and public health failing is even worse for members of ethnic and racial
minorities.
There are many reasons for this crisis: inadequate funding, lack of parity
in insurance coverage, stigma, shortage of mental health professionals, and
lack of political will to make mental health a priority. Another relates to
the focus of this hearing, namely, the challenges associated with documenting
performance and outcomes of mental health interventions.
Fortunately, we can do far better. The Surgeon General’s 1999 Report
on Mental Health established that mental health is fundamental to health. Mental
disorders are real health conditions that impose a tremendous burden on the
population in terms of disability, economic loss, and human suffering. Yet,
recovery – wherein people with mental disorders are able to live, work,
learn, and participate fully in their communities – is possible, even
expected. The literature makes clear that there is a range of well-researched
and efficacious interventions that successfully treat most mental disorders
of adults of all ages, children, and adolescents.
The hopeful findings concerning scientific advances and recovery are tempered
by the wide gap between science and practice. Evidence-based services and other
valuable though less thoroughly documented promising and emerging practices
are often not available in many communities, and implementing such practices
can be complex and difficult. Barriers impede their use, including resistance
to change by entrenched and threatened organizational structures, obsolete
reimbursement rules, and, most importantly, lack of resources necessary to
support training and dissemination and to provide incentives for innovation.
The hard reality is that millions of Americans who need mental health services
to achieve positive clinical outcomes do not receive any and, for many, the
care that is furnished is inappropriate, inadequate, ineffective or obsolete.
There are too many stark manifestations of our system’s failure, including
the 30,000 lives lost each year to suicide and the hundreds of thousands of
people with a mental disorder who are homeless, unemployed, or inappropriately
institutionalized or incarcerated.
The promise of recovery combined with the sobering reality of the enormous
gaps in the system of services set the stage for President Bush’s New
Freedom Commission on Mental Health. The President, aware of the promise, sought
to reveal and tear down the barriers to appropriate care and community participation.
Following a year of study and consultation, the Commission transmitted to the
President its report calling for the transformation of mental health in America.
The report – Achieving the Promise – is organized around six goals
that assert that in a transformed mental health system:
- Americans understand that mental health is essential to overall health.
- Mental health care is consumer and family driven.
- Disparities in mental
health services are eliminated.
- Early mental health screening, assessment,
and referral to services are common practice.
- Excellent mental health care
is delivered and research is accelerated.
- Technology is used to access
mental health care and information.
Within each goal are specific recommendations
designed to transform mental health care and improve systems performance
and individual outcomes. The
Commission recognized and the Campaign for Mental Health Reform firmly
agrees that accountability
is fundamental to each of the goals articulated in the report. An accountable
system empowers consumers and family members by enabling them to make
informed decisions about treatment. It supports policy makers and administrators
who must make informed decisions about planning and resource allocation.
It improves
the quality of provider practice and results in improved clinical outcomes.
And it is a critical in generating the political support necessary to
fund
and maintain the system.
An accountable system is one that can measure both the performance of its
programs and the outcomes achieved by the people it serves. With such data,
policy-makers and mental health providers may monitor and continually refine
their programs. They will learn whom they are reaching (and not reaching),
what supports they are providing, what outcomes they are achieving, and what
refinements or modifications are needed to enhance its effectiveness.
Leaders in the field understand the value of performance and outcome measurement,
and over the last ten years we have seen tremendous progress. There is consensus
and remarkable consistency across jurisdictions and stakeholders regarding
the outcomes that mental health systems and services are intended to achieve:
reduction in symptom distress; building social supports; community participation;
improvement in work or, in the case of children and adolescents, age-appropriate
functioning; reduced homelessness and inappropriate hospitalization; improved
general health status; and decreased contact with criminal and juvenile justice
systems. Over the past few years, states, with only modest federal support,
have worked to develop performance measurement systems along these lines. A
handful of states – Ohio, Texas, Colorado, Washington, and Oklahoma among
them – have implemented systems to obtain these data on a statewide basis,
but the majority of states are currently in the process of building such systems.
But implementing these systems is not just a matter of administrative fiat
or will. Identifying and implementing measures for uses such as planning, budgeting,
monitoring, and quality improvement is enormously complex, expensive, and labor
intensive. Resources are necessary to update or, in some cases, create information
technology systems that would enable states and counties to collect, access,
link, and analyze the relevant data. Investing in infrastructure at a time
when budgets are being slashed and public mental health systems are already
failing to provide the services and supports needed by most consumers and family
members can be difficult for states.
This suggests the critical role that the federal government must play in helping
enhance and expand performance measurement systems: first, in consultation
with stakeholders, developing meaningful measures and definitions; second,
ensuring the dissemination and implementation of these measures; and third,
funding states and counties that are creating performance and outcome measurement
systems, particularly to the extent the measures are federally mandated and
designed to present a national picture. To date, the federal commitment has
been minimal, with states receiving grants of between $100,000 and $150,000
per year to move billion-dollar systems. To be sure, SAMHSA and the states,
through changes to the mental health block grant program, are making progress
by placing greater emphasis on performance and outcome measures, but SAMHSA
must be sure that the data it is requiring the states to report are of value
not only to the federal government, but also to the states and counties in
planning, quality improvement, and contracts management. To the extent those
goals are not aligned, the federal government must be prepared to cover more
of the financial burden.
Much more needs to be done in the area of mental health performance and outcomes
measures, and we must move quickly: the future of mental health services in
this country depends on our ability to improve the quality and accountability
of mental health systems. But without the leadership, investment, and defined
expectations that the federal government is in a position to provide, the impetus
for change in this area is likely to atrophy.
We cannot, however, end our testimony here. Certainly we must consider accountability
in the context of reauthorizing the programs of the Substance Abuse and Mental
Health Services Administration. But we already know that SAMHSA programs have
value in communities. For example, SAMHSA programs play a crucial role in piloting
and disseminating information about innovative programming as well as established
best practices. The issue goes far beyond SAMHSA, however, and we urge that
you heed one of the most important observations of the President’s Commission:
that transforming mental health care in America will require fundamental change
in all social services settings at federal, state, and local levels. Although
SAMHSA must be looked to for its leadership at this time, we must not lose
sight of the fact that the resources it controls are dwarfed by those of the
myriad programs and supports that serve adults and children with mental disorders
in other systems, such as criminal justice, housing, Medicaid, Medicare, child
welfare, vocational rehabilitation, special education, and SSI and SSDI.
We are encouraged by the seriousness with which this Committee is responding
to the call of the President’s Commission. We look forward to working
with you to craft legislation that will translate that call into bold action.
A conventional approach to reauthorizing this agency will not result in transformation.
Indeed, how can the stewards of mental health care, namely SAMHSA at the federal
level, and state mental health agencies, remain accountable and properly assess
performance and outcomes when they each control only a small fraction of the
resources needed to address these needs? The lesson of the Commission is that
transforming the mental health system will require change in social services
policy broadly. If SAMHSA is to be tasked with monitoring performance and outcomes
of mental health programs, then it must be able to work collaboratively with
all of the other systems and agencies whose policies affect individuals with
consumers and their families. That will require an investment of greater authority
in SAMHSA. This, the Campaign believes, would be a sound investment. Only SAMHSA
has as its core mission the delivery of effective services to people with mental
disorders, and with so many competing interests, its leadership now is more
important than ever before.
In short, focusing on SAMHSA and the state mental health agencies and requiring
reporting of performance measures in their programs, without at the same time
looking to the performance of other programs will merely perpetuate the fragmentation
in the public mental health system and do little to advance the goals of the
President’s Commission. If we are serious about recovery and about improving
the outcomes for adults and children with mental disorders in all systems where
people with mental disorders are found, we must hold all of these systems accountable.
But we cannot do this in good conscience without empowered leadership and without
investing the resources necessary to achieve our goals.
Intentionally, the report of the President’s Commission with its enumerated
goals and recommendations left us with its own set of rudimentary performance
measures. The Campaign for Mental Health Reform, for example, holds itself
accountable for robust policy change that will achieve the outcomes envisioned
by the Commission. We view the reauthorization of SAMHSA as one measure of
our performance. We appreciate that this committee is approaching its task
in the same vein.
Thank you for the opportunity to appear this morning before you and your subcommittee.
I would be more than happy to answer any questions.
References
Daniels, A.S. & Adams, N. (2004). From Policy to Service: A Quality Vision
for Behavioral Health: Using the Quality Chasm and New Freedom Commission Reports
as a Framework for Change. Pittsburgh, PA: American College of Mental Health
Administration.
Drake, R.E. & Goldman, H.H. (Eds.). (2003). Evidence-Based Practices in
Mental Health Care. Arlington, VA: American Psychiatric Association.
Executive Order # 13263 Establishing the President’s New Freedom Commission
on Mental Health. April 29, 2002. Washington, DC.
Ganju, V., Smith, M.E., Adams, N., & Allen, J., Bible, J., Danforth, M.
et al. (2004). The MHSIP Quality Report: The Next Generation of Mental Health
Performance Measures. Rockville, MD: Center for Mental Health Services, Mental
Health Statistical Improvement Program.
Ganju, V. & Lutterman, T. (1998). Five-State Feasibility Study: Implementing
Performance Measures Across State Mental Health Systems. In Mental Health,
United States, 1998 (pp. 45-52). Rockville, MD: Substance Abuse and Mental
Health Services Administration, Center for Mental Health Services.
Ganju,V. & Lutterman, T. (Eds.). (1998). Recommended Operational Definitions
and Measures to Implement the NASMHPD Framework of Mental Health Performance
Indicators: Report of the Technical Workgroup on Performance Indicators. Alexandria,
VA: National Association of State Mental Health Program Directors.
Lehman, A. F., Goldman, H.H., Dixon, L.B. & Churchill, R. (2004). Evidence-Based
Mental Health Treatments and Services: Examples to Inform Public Policy. New
York, NY: Milbank Memorial Fund.
Lutterman, T., Ganju, V., Schact, L., Shaw, R., Monihan, K. et.al. (2003).
16 State Study on Mental Health Performance Measures. Rockville, MD: Substance
Abuse and Mental Health Services Administration, Center for Mental Health Services.
The President’s New Freedom Commission on Mental Health. (2003). Achieving
the Promise: Transforming Mental Health Care in America: Final Report. Rockville,
MD.
The President’s New Freedom Commission on Mental Health. (2002). Interim
Report to the President. Rockville, MD.
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: Department of Health and Human
Services, U.S. Public Health Service.
United States Public Health Service Office of the Surgeon General. (1999).
Mental Health: A Report of the Surgeon General. Rockville, MD: Department of
Health and Human Services, U.S. Public Health Service.
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