 So, our next speaker has the enviable or unenviable task of summarizing the themes that have been emerging through the course of the day. Thinking about the policy issues that have been raised, thinking about the policy issues that perhaps have not been raised. He's been sitting next to me for about five hours copiously taking notes, and we're looking forward to hearing you make sense of them. Dr. Richard Frank is currently the Margaret T. Morris Professor of Health Economics at Harvard Medical School, where his research focuses on mental health and substance use disorder policy, financing of long-term care services and supports for older adults. And if you've been in the field, you've read one of his many, many, many articles. He's also published a book, which we're going to ask you to comment on if we need a second edition. Better Not Well, which described basically the state of play in mental health and wellness in 2006, and see how far we've progressed. He has a unique background having served in the Department of HHS, having a strong academic record. You're able to touch a lot of bases here. So you're going to talk to us maybe for, what did we say, 15, 20 minutes, and then we will again throw it open to Q&A. So welcome, Dr. Frank. Thanks. Stand over there. As Murray said, I've been taking notes. Well, let me just start by saying I've been sort of really amazed and impressed by the social skills of the previous presenters and the emotion and the stories that we've heard today. So now I'm going to change all that. I'm an economist, as you just heard, so the social skills are gone. I'm going to talk about data, so the emotions shot, but I am going to try to put things in perspectives, and I'm going to do it in three different ways. One, I'm going to give you a little bit of history because, in fact, we've been very ahistorical today, and I think that history will allow us to put a few things into perspective. Then I'm going to raise a couple of the big themes, and then I was given permission to comment on things that were not on the table. And so I have one set of things that I'm very concerned about that I think you all ought to be concerned about that we haven't talked about. And so I'm going to make a case for why you ought to be as worried as I am. But before we do that, I do view as part of my job here as taking care not to let you all fall into the mental health policy trap, which is that nothing is ever good ever. And I've been working this field for a long time, and I remember the first time I gave a talk on costs. Costs were going up very rapidly in the 80s, and people said, ah, that's not good. We're wasting money. We're going to be targets for cost containment. This is really bad. And then cost came down. I did a bunch of analysis showing how actually mental health costs were rising much more slowly than healthcare costs in general. I go, ah, that's really bad because we're being shortchanged. We're not keeping up. We're not getting the resources. So I concluded that nothing can ever be good in this field. And so I want to prevent you from falling into that trap. So Pete's story, at once, it breaks your heart. And there are plenty of those stories around that we see every day. And, you know, you can hear hearts breaking every day. But the number of stories like Pete's is an order of magnitude smaller today than it was 20 years ago. And I don't think we should forget that. It doesn't mean that they aren't there. It doesn't mean we shouldn't attend to them, but it means that we are making progress. Second, 1972. Does anybody want to guess how many lobotomies we did in this country? We did over 20,000. Okay? 20,000 lobotomies in 1972. Now, most of you were alive. Many of you were alive in this room. I won't say most. Many of you were alive in this room. And that wasn't that long ago. And the fact that all of us are a little startled and a little horrified by that is, again, a mark of progress. Third, parity, which hasn't been mentioned much except in the last talk by the Assistant Secretary, parity has improved the insurance coverage for 170 million people in this country. Coverage expansion added 21-plus million people to the roles of people with insurance in this country. And essential health benefits mean that they all have to have both addiction coverage and mental health coverage. Now, recall, in 2011, and I know most of you were alive then, in 2011, 40% of the insurance in the individual insurance market didn't cover substance use disorders. And about 20% didn't cover mental health. Okay? Again, a mark of progress. But where we've come up short, we need to face and we need to address. But I think the solutions will require standing on the shoulders of the progress we've made. And so that's why I wanted to sort of start by reminding us that actually we've come a long way and some of the ways we've moved the ball ahead. So let me now turn to some of the key areas that were raised. I think the first one, which is sort of one of the actual great ironies of Pete's story, is our failure to engage. Because when you think about it, when he starts his story off, the first thing that happens when his son realizes he has symptoms and is to call his dad and to engage with his family. Now that's rare. That's surprising. And so I was wondering where that story was going to go and then it unfolded how difficult it is to engage. But our failure to engage is, I think, perhaps the most important story we've heard today. We've heard it in a variety of different ways. Now the good news is that we have new technologies for starting to do this. The RAISE program and some of the smaller trials that have preceded it all tell us in a very rigorous way what to do once we have that person involved in a treatment program. Bad news is that we're not yet very good about knowing how to get them there. We've done a really good job of figuring out what happens. How do we change the trajectory once we have somebody engage? We don't have good models for engaging it. We don't know how to do that. And we're not investing in research to do that job. And it seems to me that we need to do, we need to make the kinds of investment in research about outreach, about engagement, about the roles of peers, etc., in engaging people. We have to make that same kind of investment in that type of research and that kind of action as we've made in RAISE and those in the second part of the equation. And so that means learning about program design, learning about the role of peers, figuring out how to pay. Early intervention does not sit well, sit comfortably in an insurance paradigm. And in the old days we would have thought public health is a form of prevention or early intervention. We've hauled out the public health system and the public health mental health systems for a generation now. And so everything is insurance. And so we need to kind of revisit that in a different way and we perhaps need to flex the insurance model or we have to reinvigorate the public health system, but that requires important new thinking. Next, I think there are a variety of legal and ethical issues that we have to come face to face with as we think about engagement and early intervention. We're asking ourselves to get involved in people's lives at a place that didn't naturally happen previously. And we see us trying to figure out how to flex the tools that we have. The new sort of thinking about AOT. Some of the ways people have proposed using leverage in housing and public support. Those are all questions that are aimed at how do we deploy the tools that will get people engaged. But how do we do so in a way that's consistent with our values and our laws? And how do we rethink it? And that means rethinking AOT, the role of the courts and all the forms of leverage that we have. Second area that I think has come up is workforce and shortages. Now, part of the problem is in behavioral health, it's a lot about poverty. And being a lot about poverty means being a lot about public programs and you're immediately into the world of the political economy of public budgets. And one only needs to be in this town for about 30 seconds to be slammed with it. So the political economy of public budgets are, one, we pay too little in our public insurance programs like Medicaid. Two, we put too little money into public programs, be it public mental health, public health, public treatment programs of any kind. But we also have market failures. And as we've made progress on insurance, it means that we've been relying on markets. And for 35 to 50 years now, we've been struggling with how do we fairly cover behavioral health care in the context of competitive insurance markets. And parity has moved that ball forward, but it has done so incompletely. And in the context of the market failure, in the workforce market failure, these underpayments lead to underpayments of personnel and too few of them being hired. And that means recognizing that the behavioral health workforce has a set of options that aren't seen in many other parts of medicine. They have an outside option. That is, people have the opportunity to pay purely in cash outside of the insurance system and it will actually support a large portion of our workforce. And unless we recognize that and compete with it, we're not going to solve the public program, public insurance, private insurance problem. We have a cultural failure in this area. How many of you have ever heard of a guy named Jerome Frank? And he's no relation to me. Okay. He wrote a book in 1962 called Healing and Persuasion. And he has this fabulous line in that book. It's about American psychiatry. And he said, never have so many been so well educated to serve so many that didn't need it. This is not a problem of today. This is a problem that's been going on for two generations. And I think in part it has to do with money, but a lot it has to do with the way we train people, right? The stories we heard today about not being able to find a psychiatrist who treats schizophrenia. Those people aren't as much fun to treat as somebody like me, right? I like to talk about myself. They like to talk about people like me because we all went to Hebrew school together, you know? And so there you go. We need to figure out how to make markets work better. And as we make the markets work better in the insurance side and the provider side, the money will come in and we'll be able to sort of compete better in the insurance market. Part of that has to do with putting in place accountability, doing a better job of measurement, equipping consumers to make better choices, and rewarding providers to do the good stuff. Let me just make a couple of comments before wrapping up. One is the justice problem was raised. And I just think the point is that the justice interaction with the mental health system will always be with us. We will never be fully in there. The trick is to reduce the amount of effort at mental health treatment that's being done there to better equip the justice system to be partners and collaborators with the mental health system. So let me finish by telling you the big problem I have that hasn't been on the table. Since 2000, SSI for mental illness has grown about 66%. SSDI disability for mental illness has grown about 64%. If you go to the World Economic Forum, they recently put out a projection of the skills that are going to be needed in the workforce over the next two decades. Let me read to you what those are. Complex problem solving, critical thinking, people management, creativity coordinating with others. Now robotics, computers, technology are all sort of pushing those skills so that they're becoming dominant in the economy. That is great for people with physical disabilities. It is enabling them to do those things and not worry about the limitations that their body has put on them physically. It cuts exactly the opposite way on mental illness. Those are the areas of impairment that are most prevalent in connection to mental illness. What I think we're seeing is substantial gainful activity, opportunities shrinking and shrinking fast. What does that mean? Does that mean that people who are currently, who have, for example, serious depression, but are working, people who have bipolar and are working, but really have impairments in those areas that I just listed, they're not going to have opportunities going forward. That should worry us. Right now about 35% of people on SSDI are there because of mental illness. We can't create a disability state for people with a mental disorder. I think this requires rethinking a little bit about some of our clinical investments. Are we putting enough money into bringing cognitive remediation into our early intervention programs? Are we putting enough research into that area? Are we programmatically doing things? Are we relying too heavily on supported employment, which doesn't get anybody off of a disability ever, off of a disability program? We need, I think, to think really hard about this. And then I think alongside that we need to think about the design of our disability programs, SSI and SSDI. And so with that challenge, and it is a challenge that I'm taking on personally in my work, but I hope it's starting to worry you a little bit today because it's worrying me a lot. And I'll stop there. So I just want the record to show that despite the disclaimer, an economist made the room laugh. So we've got time for 10 minutes for questions. Okay. And again, I'll encourage people, mic at the front, mic at the back. I want to make sure I heard your notes of optimism and pessimism correctly here. Your optimistic note is that we're no longer doing lobotomies on people. And your pessimistic note was... I go a little further than that on the optimism side. Okay, but it was sort of in, we've made some progress in absolute terms. And yet, as I'm hearing your assessment of the state of play, we've kind of got all of the incentives wrong. We have sort of the basic model of funding perhaps wrong and we have lack of integration. We just, we don't have the right framework. And that strikes me as sort of a hard thing to solve. Well, let's, you know, think about it. We, until recently, we took the concept of insurance, right? All of you know what insurance is, right? You want to protect against big losses. You don't care that much about little stuff. So you buy insurance against the house burning down, but you don't worry about a broken window. Well, the mental health system until 2008 was exactly the opposite of that. You were pretty well covered up to your first 30 days of hospitalizations or up to your first 20 visits. But if you got really sick, you were SOL, as they say. And so I think that we've really made progress on that. I think the combination of parity, the coverage expansions has really made a difference on that. And look at all the parity evaluations, they all say it doesn't cost that much, but people who are really sick are much better protected today than they were 10 years ago. So I think that that's an important part of it. But I think I think you're right that we continue to struggle with incentives. We continue to struggle with the political economy of public budgets. Go to the mic. Hi, Dr. Frank. Dr. Debbie Plotnick, Mental Health America. By the way, I just loved your book. Got to say. Looking forward to the next edition. However, I would like to address one of the points that you made and how it is that our policy issues have contributed to it. So you heard today the need for more AOT use. You yourself spoke about increases in SSI and SSDI. When we put that in the context of what we heard in Pete's story, what I hear in my role at Mental Health America and talking to groups and individuals and people all across the country is that they are not engaged. They don't want what is being offered. What we are offering as a policy solution to people not getting what they want. And most folks like Pete's son and most of the folks that I know and just better ready to talk to in the beginning will engage. They want help. They reach out for help. The help that is offered is not the help they want. And therefore, they are ending up in the criminal justice system. They are ending up. And one of the policy solutions being put forth is to further compel them to a system that hasn't served them well. Would you kindly address that? Sure. So I think there, well, there are a lot of dimensions of that. First thing, I do think that the kind of traditional doctor-patient model where doctor sits in their office above the garage and has a couch and all that and a prescription pad and they wait for people to show up. That clearly is one of the things that's not working. And that's why I think that investment that I talked about in figuring out how do we really engage people early is sort of at the heart of all this. And I think it requires a different mentality. But it's also, it requires a different team. And, you know, this is increasingly becoming a team sport, an organizational arrangement sport. And so that's where I think the money, the regulations have to go. But I don't think that's so much a matter of our policy. You know, RAISE and its precursors are still relatively new things. We didn't know what we were doing. I mean, we still don't know what we're doing because we don't know which model to have. And what we have right now is with the block grant set aside, we have 50 experiments going on. And if we don't learn about some of the things that worked best in the outreach and engagement stuff, shame on us. We're not doing our job. Just building on that. And Chuck kind of referenced this earlier, the role of patient attribution and payment models. And I was curious if you could say a little bit about the potential role of attribution or lack of role in promoting engagement as we move forward in healthcare financing. Well, I think... Do you want to just clarify for people who aren't... Attribution means kind of in these new payments systems like ACOs, like who is your patient? Who's enrolled with you and who isn't? So, like, my mother was in Medicare and she got a letter saying you're now in an ACO. But in fact, if you go to another doctor, it's okay. You don't really have to be in the ACO. We won't tell you, you won't tell us, and it'll all be okay. And so what I think what he was referring to was don't you think it's a good idea for accountability and a variety of other reasons to sort of have the system and the patient actually link together. And that then creates an incentive because total cost of care is what you're at risk for to be careful that you manage that person effectively, don't get them into the hospital, don't get them into the more expensive setting, engage them early, et cetera. I think that's true in theory. If you have an accountability system that dings people for taking shortcuts and rewards them for doing the right stuff. Because otherwise, it's really easy to duck our patients. That's the history. The neglect came from how easy it is to duck folks. So you're in the appropriate temple to preach on behalf of integrated systems and full capitation. Absolutely. I worry a little bit though that the... If I was at Blue Cross at Blue Shower, you'd answer that completely differently. But aren't some of the payment carve-outs sort of well-motivated to saying we want you to be in a team-based environment for your mental health care, but we're now going to divorce it from your physical health care? I'm about to go on my annual rant on the carve-out controversy. So the good side of carve-outs is that it takes advantage of economies of specialization. So let me remind you, there was a randomized trial done in Baltimore a few years ago where they gave primary care docs information about diagnoses of depression of their patients because they did a screen. And they randomly assigned them to doctors that didn't get that information. Turns out it made no difference. They knew, but they ignored. Similarly, there was a study done of videotapes of primary care offices a few years ago. The title of the paper that came out of that is the one-minute office visit because, in fact, a patient would raise a mental health issue with their primary care doc and would take them one minute before they switch their subject to something else. How about those Red Sox? And so, in fact, pure primary care wasn't always a great place for people with mental illness to show up. Carb-outs helped that a little bit. In fact, carb-outs is what got us parity. I think we're, though, into a new generation. I do think integration is better. I think carb-outs create some problems because they don't align well with all the providers that a patient sees and they hamper communication coordination. So as we've progressed, I think we either need to rethink the model, and I think that is being re-thunk, or come up with more alternatives. So that's sort of the balance. So, in a sense, they were good. I think we're starting to outgrow it. Okay. Please join me in thanking Professor Frank. Thank you.