I have a friend who is a Navy lifer, and he said it’s easy to figure out in a large group of officers who the pilots are. “Give ’em two minutes and they’ll tell you,” he jokes.
We’re all guilty of that little indulgence, aren’t we? We love to brag a little, even if its something as routine as being a parent, or being a doctor, or living in a particular place. However, those of us that work in public health and social services tend to take a different spin on it: We can’t wait to tell others how bad we have it. Often when we’re working with someone from – pick a state – within a few sentences of the introduction something like this comes out:
“We’re number one in the country in (pick a distinction):”
- heroin overdoses
- meth use
- alcohol abuse
- pain medication addiction
And it might well be true. Someone’s got to be number one each of those things. In fact, one time during introductions in a training we had two groups from two different states debate with each other who was number one in a particular malady.
Beyond that, we all tend to believe our area to be unique. Folks will often start with “well, I don’t know how it is in Tennessee, but here in (insert state) it’s much different.” And it is. Every state is different is some aspect or occurrence. All problems are unique. They might have similar bases, but their impact is varied according to a multitude of regional variances. But of that list above, is there any one region of the country immune to any of them? Does it really matter in the grand scheme who is number one by any ranking or definition? Take for example this study that ranked deaths per 100,000 people due to drug overdoses (Prescription Drug Abuse: Strategies to Stop the Epidemic. Trust for America’s Health, October, 2013). According to this data, West Virginians can claim top billing, while folks in North Dakota might claim superiority of its efforts. I’d bet if we talked with safety net providers in North Dakota, though, they might tell a different story. Just this past week, in fact, there was a story in the Williston, N.D., news about a string of heroin overdoses in the last several days where a person died and eight more hospitalized. The reporter states that while drug overdoses are on the increase across the state, she could not corroborate it with police or the local hospital which stated it doesn’t release that sort of data (Hacklenburg, E., 1 Dead, 8 Others Treated After Overdosing on Heroin in Williston. Forum News Service, Jan. 11, 2016). I’ll bet to the people in Williston it feels like they might be the top ranked region for heroin deaths right now.
There is even a term for this phenomenon: The primus inter pares effect, or “first among equals.” It is also referred to as the above average effect or in more contemporary phrasing as the Lake Wobegon effect where “all the children are above average.” Except in our case, instead of being of above average intellect or good looks, we’re above average in terrible things like diabetes and mortality, which, I suppose, evokes a sense of empathy from others as to how bad we’ve got it here in (insert state).
Studies and rankings are important because we have to have some sort of context, and be able to learn what is working somewhere else. The rub comes when those rankings wear us down, when they erase all hope. When they become an obstacle, or excuse as to why nothing new will help. “We can’t do integration like you all in Tennessee because”:
- “Our Medicaid system is different”: Yes. They all are, thanks to President Reagan. Some will be more restrictive, and some will be more integrated care-friendly. That’s true.
- “We can’t do same day billing”: That is another obstacle. There remain some portion of states that have not allowed two separate billed services in the same site on the same day, for example between a family practitioner and a BHC.
- “Our CFR-42 Rules are more restrictive than yours”: There are states that have more restrictive standards above and beyond CFR-42, particularly with substance abuse. Another hurdle, for sure.
- “We don’t have the workforce like you do”: We do have a BHC post-doc internship where we grow our own BHCs, that’s true.
- “We’re in a managed care environment”: Some are very new to it, some have had for a long time, others not at all.
- “We’re rural.”
- “We’re frontier.”
- “We’re urban.”
- “We’re deeply impoverished, uneducated, and cash-strapped.”
- “We have a crazy Governor.”
Those are all real issues. They are all real obstacles that require a lot more than just showing up. But not a one is a death knell to integrating primary and behavioral health. In fact, not even a cluster of them can prohibit the practice. That’s not to stay it won’t be a challenge and require strategic alliances with primary care associations, provider networks, payers and stakeholders in order to aggressively advocate when necessary. We’ve yet to find one state – and we’ve worked with just about all of them – where it is impossible.
Our problems and challenges aren’t really so unique, but our solutions have to be in regard to the resources available. Our biggest challenge is not to focus on what makes us the “number one” in some certain disparity, but rather view that as an opportunity. I recently participated in an interview process with a potential BHC of a health center of which I’m affiliated. I asked her one simple question: “What problem do you want to solve.” If you’re concerned about heroin or obesity or diabetes, let’s focus on the solutions and how increased access, more efficient and effective teams, and a stronger workforce can address it. A best practice is a best practice regardless of any of these factors. If payers insist on paying for anything less than the best practice, then the payer has to change, not the practice.