National Campaign for Mental Health Reform

National Campaign for Mental Health Reform

Campaign for Mental Health Reform Calls for Improved Performance and Outcome Measurements in Mental Health

WASHINGTON, DC (July 20, 2004) - Dr. Howard Goldman, a nationally recognized expert on mental health policy, today called on lawmakers to enact reforms to improve accountability in the public mental health system.

Appearing before the Senate Health, Education, Labor, and Pensions Committee's Subcommittee on Substance Abuse and Mental Health Services, Dr. Howard Goldman testified on behalf of the Campaign for Mental Health Reform that public mental health systems must be held accountable if Americans with mental illness are to achieve the promise of recovery and live full lives in the community.

"An accountable system is one that can measure both the performance of its programs and the outcomes achieved by the people it serves," said Goldman to the subcommittee. "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."

Goldman noted that despite the existence of effective treatments and services, the majority of individuals who have a diagnosable disorder do not seek or find the help they need.

The federal government must play a critical role in helping states enhance and expand performance and outcome measurement systems, according to Goldman. Further, he said, the Substance Abuse and Mental Health Services Administration (SAMHSA) must be given authority to work with a broad range of federal agencies to gather data.

"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," said Goldman. "If we are to take transformation seriously, we must empower SAMHSA to work with all agencies in its stewardship of the system."

Dr. Goldman is a professor of psychiatry and Director of Mental Health Policy Studies at the University of Maryland. He also served as both senior scientific editor of the Surgeon General's 1999 Report on Mental Health and consultant to the President's New Freedom Commission on Mental Health.

Dr. Goldman's full testimony is available online at:

http://www.mhreform.org

The Campaign for Mental Health Reform has been organized as the mental health community's united voice on federal policy. Its goal is to make access, recovery, and quality in mental health services the hallmarks of our nation's mental health system. Its members include organizations representing millions of people with mental or emotional disorders and their families and service providers, administrators and other advocates.

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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.

Source: Campaign for Mental Health Reform

Source: Goldman Testimony

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