On Monday, June 22, 2015, MJB’s Smokler Center for Health Policy Research held its second Larry Lewin Memorial Symposium.
The symposium was held in memory of Larry Lewin, long-time member of the Smokler Center’s International Health Advisory Committee (HAC) and a pioneer in the health care policy field in the United States for many decades.
This year’s symposium focused on the upcoming reform of Israel’s mental health care system, in which responsibility for mental health care is moving from the government to the four national health plans and is being included in the basket of services provided under national health insurance. The transfer of responsibility was originally intended to be included in the 1995 national health insurance law, but its implementation was repeatedly delayed over the years.
MJB Director Prof. Jack Habib set the stage by acknowledging the controversies surrounding the implementation of the reform. “There are those who applaud the reform, and there are those with concerns,” he said. The goal of the Symposium, however, was to focus on a thoughtful engagement of the reform, how it can be understood in a larger and historical international context, and how it can best be monitored.
The seminar opened with presentations from Prof. Arnon Afek, Director General of the Ministry of Health, and Dr. Tal Bergman, Director of the Ministry’s Mental Health Service. Prof. Afek provided a historical overview of the reform, while Dr. Bergman delved into the nuts and bolts of what is happening.
Like Prof. Habib, Dr. Bergman noted that the journey to implementation had its ups and downs, with disagreements among the different stakeholders. Nonetheless, “the disagreements were healthy for the process,” because they raised important questions and pushed the Ministry to clarify and refine its approaches. The result, she explained, will be a system in which “more primary care physicians will be more aware of mental health,” which will ultimately result in better access to care for everyone.
As with many of Israel’s most important national social reforms, MJB has been chosen to monitor the implementation of the mental health care reform. In his presentation, Smokler Center Director Dr. Bruce Rosen explained that monitoring is essential to helping policy makers and others refine the design of the reform and improve the implementation. In this role, MJB will draw on the knowledge gained in numerous studies over the past few years that have established baseline information about the mental health care system.
The Symposium’s keynote presentation was delivered by Prof. Sherry Glied, Dean of the Wagner Graduate School of Public Service at New York University and an international expert on health care policy and mental health care reform. (See video above.)
Drawing on her extensive research of mental health care in the United States, Prof. Glied took the audience on a journey through the intricacies of the system and highlighted both the advantages and potential challenges of having mental health care integrated into the primary health care system.
One benefit is related to the medicalization of mental health care. While many see medicalization as a totally negative trend that leads to over-reliance on drugs. Prof, Glied argued that giving a mental health care problem an actual medical diagnosis can also help to more clearly identify and explain a problem that might have gone unexplained or attributed to an abstract and unmeasurable cause of “poor parenting” or “general unhappiness.”
Additionally, the integration of mental health care into the primary health care system offers potential opportunities for improving the treatment of people living in poverty and from culturally disadvantaged backgrounds. Typically, these populations are familiar with and tend to use clinic-based primary care, and are less likely than others to track down mental health care specialist on their own. But if their primary care physician has ready access to a mental health care professional as part of the clinic, they will more likely to enter care this way.
Still, Prof. Glied warned against being overly optimistic in what mental health care reform can bring. For example, a review of dozens of evidence-based studies showed many are very cost-effective—that is, they seem to work at a relatively low cost—but almost none actually save the system money. In other words, cost-effectiveness does not necessarily equal cost savings, and “if policy makers are undertaking reform with the intention of saving money for the system, they will probably not succeed.”
Prof. Glied also cautioned against cost shifting. Simply put, people with serious mental illness are expensive to treat, and insurance systems have incentives to look for ways to shift the costs to other systems, whether to the criminal justice or welfare systems or even to places outside any formal system of care. Some people looking for mental health care might be encouraged to speak with their rabbi or friend for free, rather than with a mental health care professional who costs the insurance plan money. This is something that would never be accepted with a traditional medical problem, and should not be accepted with mental health care, she argued. “If you needed a heart bypass, you wouldn’t go to your rabbi for the operation, so why should it be this way for mental health?”
One antidote against cost-shifting is measurement. “If you can set standards, then you can measure what the health plans are doing. This makes the health plans accountable for how they spend their money.”
Finally, as the responsibility for mental health shifts from government to the health plans, Prof. Glied reminded the audience that there remains a need for the state to stay involved as a way to give a voice to the mental health care consumer. With integration into the primary care system, mental health becomes just one more in the list of medical services available, without a dedicated advocate.
In a key exchange during the question period, a representative from the Israeli Psychologists Association raised the oft-repeated concern that the new system will end up leaving out those who most need help. “If we offer everyone treatment, then the very sick might not get treated because they are expensive, and there will not be enough money for them.”
Prof. Glied agreed wholeheartedly with the concern, and reinforced the notion that everyone in need should get treatment. The question for her, however, was “treated by whom?” In an environment with limited resources, those with the most complex and serious problems should be treated by those with the most experience and training—psychiatrists and psychologists, specifically. At the other end of the spectrum, family doctors or others with less specialized training can easily treat a problem like mild-to-moderate anxiety—and at lower costs than a psychiatrist or a psychologist. “The question is not about who should be treated, but about how to allocate resources.”
The Symposium was held in the context of the semi-annual meetings of the Smokler Center’s international Health Advisory Committee. Committee Chairman Prof. Gary Freed lauded the fact that the discussion was substantive and not emotional. He attributed it to the fact that “MJB is clearly seen as an unbiased arbiter, a safe, neutral place” for people on all sides of an issue to have a discussion. Marion Ein Lewin, committee member and widow of Larry Lewin, noted the “good representation from the different constituencies involved in the reform.” Calling the Symposium “very informative and timely,” she reflected that Larry would have been very pleased with the discussion, because mental health care was a topic that he was quite interested in and cared about deeply.