Pressure has been mounting in Florida and across the country for state departments of health to take over regulation of public and private treatment providers, the thought being that we have for far too long bifurcated healthcare at the neck.
We had previously written about NJ Gov. Chris Christie announcement on July 11, 2017, of his decision to reorganize the $1.2 billion NJ agency (Dept. of Human Services) in charge of mental health and addiction services. In NJ, that agency is funded at a rate of approximately 10:1 as contrasted with Florida and other states, where the local humans services agency tends to be the least funded and the one with the lowest morale. (To that point, Palm Beach’s WPTV (NBC affiliate) ran a story on July 28, 2017, about how Florida’s Department of Children and Families’ employees were falsifying records relating to child welfare inspections simply because they were overworked, overburdened, and underpaid.)
Back to NJ, last week, experts appeared before legislators in Trenton to testify on how the plan, proposed by Gov. Chris Christie, to shift mental health and addiction services to the state Department of Health would create probable disruption for providers and clients.
“While we strongly believe integration of behavioral health and substance abuse is important to integrate with physical care, we believe this move is not a viable way of making this happen,” said Barbara Johnston, director of policy and advocacy for the Mental Health Association in New Jersey.
The shift could involve moving millions in state funding, a couple hundred employees and regulation changes between the two departments.
According to a copy of his reorganization plan, Christie said the shift would “remove bureaucratic obstacles to the integration of physical and behavioral health care, and effectively address substance-use disorder as the public health crisis that it is.”
A Physician’s Perspective
We interviewed Dr. Robert Moran, a well-regarded South Florida psychiatrist who specializes in addiction medicine. He is also the founder, CEO and Medical Director of the Family Center for Recovery in Boynton Beach, Florida.
Psychiatric illness means that an organ of the body is dysfunctional–the brain. It is silly and naive to think that a social service agency is capable of overseeing the licensure and quality of care of psychiatric treatment centers. It is also misguided to see the disease of addiction as something that should be treated differently than other psychiatric illnesses; that is, in a ‘rehab’. As a physician trained in medical school to diagnose all medical illnesses, I do not see brain illness differently from heart or lung illness with regard to the fact that we illicit symptoms, identify signs, make diagnoses and prescribe treatment. Of all the medical specialties, psychiatry is the most difficult and most sophisticated. [DCF has] no idea as to whether we are providing quality standard-of-care because they have no medical training. They may see that I have a patient on 7 psychotropic medicines and have no idea whether it is appropriate, but they will point out that one digit in the phone number for the abuse hotline is incorrect.
I, personally, am licensed by the [Florida Department of Health]. My psychiatric practice is under their auspices. The treatment that I provide to the patients in my facility should be monitored by that same agency.
Moving licensure and oversight to DOH is not only logical, it is absolutely necessary if we expect to get the opioid epidemic under control. DOH knows what standard of care is for all illnesses. It is able to recognize when a facility/practitioner is not meeting the standard. DOH would be able to identify that a licensed entity is not recommending anti-craving medicines which have been proven to decrease use of substances (almost all patients referred to us from other facilities have not been offered/prescribed proven anti-craving medicines at the referring facility).
The Perspective of Recovery Support Providers
The majority of speakers said they favored more integration but not at a time when community agencies are already undergoing a major transition from a contract-based payment system to a fee-for-service system.
Johnston and others said the timing for reorganization of the mental health division, which oversees community-based mental health and substance-use programs, the state’s four psychiatric hospitals and other behavioral health programs, could hurt agencies already struggling with the payment transition.
Debra Wentz, CEO and president of the New Jersey Association of Mental Health and Addiction Agencies, said on top of that, uncertainty on the impacts of what a federal health care repeal could do to mental health and addiction services in New Jersey is another reason for hesitation.
Others were hesitant to separate mental health and addiction services from wrap-around services such as housing, food assistance, employment, Medicaid oversight and others that currently exist within the human services department.
John Lehman of the Florida Association of Recovery Residences brings a unique and educated perspective to this issue, particularly the interplay between treatment and recovery support services:
Though integration of SAMH [Substance Abuse and Mental Health] and Medical Healthcare continues to present challenges to New Jersey, Florida and many other states, the greater challenge is the profound failure of federal and state agencies to fully embrace recovery-oriented support systems. Contrary to much rhetoric, recovery support systems are largely ignored by payer systems. This results in what can be described as the Catapult Practice wherein persons exiting quality addiction treatment are launched towards mutual aid and other recovery support platforms in hopes they will make it across the relapse chasm. Over two-thirds fail to cross the divide resulting in either premature death or repeated and costly episodes of acute care. We must build bridges to recovery predicated on evidence-based practices and interventions appropriate for delivery by credentialed peers in nonclinical settings. One of the most appropriate settings from which to provide these evidence-based interventions is certified recovery residences measured to be complaint with NARR Quality Standards.
John Jacobi, Seton Hall director of the Center for Health and Pharmaceutical Law and Policy, said years of research and study on integration issues has shown that the fragmentation of health care delivery systems is one of biggest issues legislators have had to face.
Jacobi said regardless if the plan gets passed or not, integration between mental and physical health must happen, which should include a streamlined process where providers can get a single license to provide behavioral, substance and medical treatment.
“I believe, from our research, that behavioral health integration saves lives,” he said. “That reform of New Jersey’s licensure system for outpatient care is necessary, but the process for integration is a long one.”