LOS ANGELES — A proposal to integrate the Departments of Public Health and Mental Health with the Department of Health Services in Los Angeles County has taken its first step toward reducing bureaucracy and improving efficiency, supporters say.
At the same time, some of those in the county’s mental health sector worry that their collective mission will get lost in the shuffle of such a behemoth transition, and they haven’t shied away from saying so.
Supervisor Michael Antonovich wrote the proposal and presented it last month, drawing heated, emotional comments from mental health advocates, who said a vote on such a major change was too much too soon.
Supervisors voted to move forward with a modified proposal. The first phase of health integration allows 60 days for preparation of a draft report for board submission with input from stakeholders. The draft is due March 13. The second phase calls for a 30-day public hearing and comment period on the report through April 13, with a final report due to the board on May 12.
Earlier this month, county officials released a Jan. 2 memo from DHS Director Mitch Katz to the supervisors, originally marked “confidential.” He proposed that the three departments operate as an integrated agency, and that he head the new unified health department.
He noted that the three departments were once “a single organization,” and then separated over time. Calling the moves “appropriate at the time,” he said “evolving trends in health care delivery, policy and reimbursement have changed things.”
Seeking Structure and Coordination
“Each board member made clear on the day the item was discussed that what they’re looking for is structure of the organizations that would enhance and improve services and the coordination of care across mental, physical and population health,” said Fred Leaf, senior health policy adviser for Antonovich. “The one thing everyone agrees on — no matter what form this actually ends up taking — is that there needs to be a better coordination of care.”
New requirements under health care reform include expectations for managed care plans and a model of care that promotes treatment of the “whole person,” Leaf said.
The Substance Abuse and Mental Health Services Administration and National Council for Behavioral Health said in a statement that “barriers to primary care — coupled with challenges in navigating complex health care systems — have been a major obstacle to care [for them].” The solution, they say, lies in the systematic coordination of general and behavioral health care.
“We have tremendous resources on all sides, but if you don’t connect them in a really efficient way, people fall through the cracks all the time,” Leaf said. Addressing the concerns of the mental health community that a reduction in services or budget would take place, Leaf said, “There’s no indication or evidence that this would happen.”
The memo from Katz outlined benefits of integration that include better care, better response to health plans’ expectations, improved prevention and early intervention strategies, along with better cost control and increased revenue.
The vision statement of the future Office of Health Care Integration states that each department would maintain its own director, budget, mission, and strategic priorities to enhance the level of services, including improvement of access and quality.
“Services, budgets and staffing for patient care and population health programs will not be cut and financing streams will not be redirected because of a transition to the integrated agency model,” the statement says.
Size Does Not Matter
Katz cited benefits of a merger for consumers. “People with physical health needs, mental health needs and substance abuse treatment needs wouldn’t be required to go through a separate eligibility process each time.”
He said he’s seen a great outpouring of support for the recovery model that mental health has used so successfully, and that it could work for people with other chronic diseases.
“People with mental health needs don’t always perceive themselves as having those needs and, therefore, aren’t always currently engaged in the mental health system — but they are engaged in the physical health system,” he said.
“Some believe their problem is a physical problem — a migraine or severe abdominal pain, for example. Maybe the other side of the coin is that people with severe mental illness aren’t getting good physical health care,” Katz said.
A study published this month in JAMA Psychiatry found that the risk of mortality among people with mental health disorders is more than two times higher than for people without such issues.
Most departments in California are integrated, Katz said. “Part of what makes L.A. different is its large size, a county of 10 million people. I understand that people feel it’s so big, but if something was truly too big, you might create — as L.A. did at one time — service areas that provide integrated services within an area. Size seems the wrong reason to separate delivery systems into three different departments. It seems to me that dividing along discipline lines creates silos, and that we can figure out how to do a better job.”
“Let’s celebrate what’s working, and look at those areas where things could be better,” he said. “When I hear from someone that ‘My care is great,’ I think that’s wonderful. But that doesn’t in any way invalidate the possibility that there’s a population that needs something different.”
No Separation Anxiety
“We’re very concerned as we’ve expressed publicly from the beginning, and people in public health have the same concerns,” said Bruce Saltzer, executive director of the Association of Community Human Service Agencies.
“We feel the need to have a separate voice, and our concerns and our cultures are very different. We’re very much coordinated, very collaborative, very community-based,” he said. “One major point of contention is that integrated governance does not necessarily equate to better integrated care.”
Saltzer said L.A.’s Health Services Department operates under a medical model, while the mental health system is consumer and family oriented, based on a psychosocial rehabilitation model for adults and a resiliency model for children.
He also expressed concern about the significant level of disruption that could occur with merging three large departments under a single agency, based on his own experience merging significantly smaller mental health and child welfare associations ten years ago.
At the Los Angeles County Council Headquarters of the National Alliance on Mental Illness, executive director Brittney Weismann said she has a lot more questions than answers about the proposed integration.
“Collaboration is a good thing, but rushing into the decision process by the Board of Supervisors and county officials created trust and credibility issues for us and alienated some other stakeholders,” she said.
“It’s not going to be our decision whether these entities merge, but we will have to deal with whatever comes,” Weismann said, echoing Saltzer’s concerns. “When agencies share a large mega-bureaucracy, they tend to overlook mental health, which becomes a stepchild to hospitals and clinics. We’re afraid our strong community models will be diminished or diluted.”
County Public Health Commission Chair Jean Champommier said his formal Jan. 30 response to the supervisors shared concerns about the new agency and underscored the need for sufficient stakeholder input.
The letter noted that since L.A.’s DPH became separate, “it has been more successful and able to make great strides in population health.” Previously, it suffered adverse effects “due to lack of resources and the inability to prioritize population health issues relative to personal health.”
At the Hospital Association of Southern California, Vice President of External Affairs Jennifer Bayer said she and colleagues are watching closely to determine exactly what the merger goals are and how they will be measured.
“We don’t have a formal opinion, but because the infrastructure around mental health is so fragile in general, this needs a very sharp lens. We want to make sure services are protected and expanded to the best of the county’s ability,” she said.