Center on Psychiatric Disability and Co-Occurring Medical Conditions

State-of-the-Science Summit on Integrated Health Care

Center on Psychiatric Disability & Co-Occurring Medical Conditions

Lessons from Abroad in Integrated Healthcare - Marianne Farkas

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European countries. Why should we care about European healthcare? Well, as you may know, the United States has the highest overall spending in health care of any industrialized nation. The lowest percentage of its population covered by government healthcare programs as well, according to a survey done in 2006. So, together with this spending, unfortunately we also have the highest rate of deaths, that could be amenable to health care interventions in the industrialized world. What does that mean? It means that we have the highest rate of death from heart attacks, strokes, diabetes, bacterial infections, etc, that we could do something about for people who are under 75 years of age, in the industrialized world. So for example, the United States had 95 deaths per hundred thousand in 2012, from such illnesses, while France had 55 deaths per hundred thousand in that same year. Basu (2012), a healthcare economist, theorizes that among other things, these poor outcomes relate to differences in the countries in its social welfare policies, in the degree of income inequality, the availability of high risk products like alcohol, tobacco, high-calorie-low-nutrient foods, which all play a role in this discrepancy.

So what does this have to do with integrated healthcare? Bottom line is, in general, we are not getting our money’s worth in healthcare. The discrepancy between the cost for our health care and the value we get for our money also contributes to the problems we have in helping people with serious mental health issues get the physical and mental health care they need, to overcome the gap in life span that exists between those with diagnoses of serious mental health issues and those without such diagnoses. And that is 25 fewer years than the average American. Can we learn anything about integrated care from countries that have better overall health care systems? To understand this, we have to first take a look at the basic differences. The underlying philosophies in the United States and countries like the Netherlands and Sweden are different, and they play a role in how health care is viewed. So, for example, in the US, we value self-sufficiency (i.e., taking care of yourself, pulling yourself up by your bootstraps). We think a government is necessary, but we see government support pretty much as a last resort, mostly for survival kinds of issues. So, FEMA, providing hurricane disaster relief, or if someone has been unemployed for reasons that are not of their own doing for long periods of time, the government can and does step in and extends workmen's compensation benefits, etc. We see government support as the last resort. In the European Union, or the social democracies, healthcare/ being healthy, the state of well-being, is seen as a basic right for citizens of the country. It’s a right. The government takes a lot of taxes from individuals for the collective good, and that’s seen as a positive. In return for those high taxes, citizens of countries, such as the Netherlands and Sweden and other Scandinavian countries, get free education, low cost to free healthcare, support in their old age, etc. So they are willing to take that trade off, if you like.

Let’s talk about the Netherlands, in specifics. The Netherlands has been rated as having the best healthcare in the industrialized world- the lowest cost and the highest health outcomes for its dollar. The Netherlands requires its citizens to buy basic health insurance. The government defines what basic health insurance should be, and by law every citizen has to have basic health insurance. So there are no uninsured people in the Netherlands. You can buy more insurance for more coverage if you want to, but that’s your choice. Healthcare for people with long term conditions, however, is automatically paid for by the government. Until about ten years ago, health care for people with serious mental illnesses, was provided within the context of institutional care. Institutional care, which meant psychiatric hospitals, included inpatient care and some outpatient services for those who were discharged from those hospitals. However, the rate of de-institutionalization was very slow in the Netherlands. In the period of time when the US decreased its hospital rates by 75 percent, the Netherlands decreased its hospital rates by only 10 percent, which meant that until recently, up until 2004 or so, most people with serious mental illnesses were treated inside psychiatric institutions. Beautiful institutions, mind you, but still institutions nevertheless. There was very little movement from inpatient services to community based care, although many community based institutions were in fact emerging in that time period. More recently the government has begun cutting back its long term care support, but building psychiatric units within general hospitals like we have, and attaching more psychologists to general practitioner offices, called primary care in Europe, to deal with behavior problems and everyday emotional issues. It has also merged its funding streams so that physical care and mental health care are funded by the same government entity to reduce barriers in integration. However, as more people are transferred to community care, and fewer funds are available, many of the same issues of fragmentations of services for individuals with serious psychiatric conditions are emerging in the Netherlands, that the US has faced. These are [issues such as a lack of communication, the fact that there few providers of general medicine who are trained to work with people with lived experience, and the lack of attention to preventative care, etc. So what does the Netherlands have to teach us about integrated care, even though its healthcare system is really excellent? Unfortunately, not much.

Let’s turn to Sweden for a moment. In Sweden, the entry point for health care for all is primary care. There are secondary levels of care as well. That is specialty care, so if you need a dermatologist or a specialist of some kind, you go to what’s called the secondary level. The tertiary level of psychiatric hospitals and long term care hospitals exist to be used if needed, but everyone has a primary care physician and must go through those practices to get to hospital care. Primary care, however, gets funded by the number of patients who are enrolled in any one particular practice. If a person does not make a choice about which primary care office or which GP practice they want to belong to, they are assigned to one by the government. 70 percent of Swedish citizens get care in the public sector; 30 percent pay privately. So it’s still pretty much a public sector system. The government gives a certain amount per patient. But the money follows the patient and therefore if the patient doesn’t like a particular general practitioner's office or the care they’re receiving, they can go and register at some other practice and the money that is paid for them goes with them. The system is designed to pay more and give more resources for higher needs; therefore, healthier people produce less revenue for these practices. General practitioners get extra money for providing preventative care; that is, discussing smoking, exercise, etc. If they use fewer secondary or tertiary services, that is specialist or long term care, the practice gets a bonus, so they are motivated to keep people healthy and within their own practice. As the Swedish government system became more aware of shorter life expectancy for people with serious mental illnesses or psychiatric conditions, the government gave more money to general practitioners to meet with folks around their physical health. Sounds wonderful.

However, in reality, one of the problems that has emerged over time is that GP’s are not seeing as many people with lived experience as had been hoped. The main issue has to do with the fact that the average general practitioner sees three to four patients per hour, because, remember they are paid by the number of patients they see. So each person gets about fifteen minutes, kind of like our general practitioner offices. And this works for average physical health care. One of the problems in getting people in general practice to serve people with serious mental health conditions or psychiatric conditions is that working with people really takes more time--more than fifteen minutes. For most folks, the idea of taking tests, getting blood work, taking clothes off is an uncomfortable process, as it is for anyone. For someone with trauma issues, with problems focusing, with problems of engaging with practitioners, with any kind of barrier to receiving services, it just takes more time--it could be an hour. However, the general practitioner is not paid for an hour of service; they are only paid for those fifteen minutes. If the person is referred to a specialist, the specialists are leery of serving folks with lived experience because often the same issues get in the way of people showing up for those appointments, making the appointments, following through on the appointments, dealing with transportation issues, etc. Whereas within a psychiatric institution, they have physical and mental health care integrated under one roof. So in Sweden there is no structural barrier to collaboration. People do try to communicate, etc. But in practical terms, the incentivizing system makes it difficult for general practitioners to really provide the kind of in depth services that would be needed, to produce better outcomes for people with lived experience. In addition, the same concerns that occur in the Netherlands and the US, occurs in Sweden. That is, the lack of training for general practitioners on how to best serve individuals with lived experience and their multiple concerns; the lack of support, rehearsal, and preparation for people before they go to the general practitioner’s office; knowing what to expect; how to be a self- advocate and involved patient; etc.

In conclusion, what are the lessons we can learn from the Netherlands and from Sweden? We learn that, even in systems with better general health outcomes provided at a lower cost to the public, the integration of medical care and mental health care, outside of psychiatric institutions, is a universal problem still in search of a solution. Thank you for your attention.