The second half of May and first half of June were a challenging time for us. Two elderly parents had acute medical needs at the same time in different cities. Both were hospitalized, one in a critical care unit.

During this time I found myself thinking about different aspects of the experience. For those of you who have not yet had the responsibility to care for an elderly parent, these issues might be interesting to look forward to. For those of you who are our age-mates, you will probably have additional issues to offer.

1. Medicare mostly works. (Medicare with a secondary insurance works even better.)
2. Health care workers, for the most part, really seem to care.
3. The quality of care you receive depends upon your ability to advocate for yourself…or to have surrogate advocates.
4. In the heat of the emotional moment, having siblings helps, even if they are in a different state.
5. A Health care Surrogate, an Advance Directive, or a Living Will are not optional.
6. The toll on family caregivers is huge.

1. Medicare mostly works. Medicare with a secondary insurance works better. I know doctors complain about Medicare and the amount they are reimbursed and about dealing with Medicare claims. I also know that health care services are provided without question when Medicare is the payer. In an emergency situation, not having to be concerned about the method of payment allows everyone to focus on the care of the patient. I think there is a great deal to be valued in that.

2. Health care workers, for the most part, really seem to care. Health care workers are overworked and hospitals are understaffed. Nurses and nurse technicians are responsible for so much documentation that they often feel that direct patient care gets shortchanged. In two separate hospitals in two parts of Florida, my experience was that hospital staff did an excellent job in spite of the demands on them…and that they really cared about their patients and about the job they were doing for them.

3. The quality of care you receive depends upon your ability to advocate for yourself…or to have surrogate advocates. Without a spouse and/or children or some other sort of advocate, people do not get as good care as when an advocate is present. The reasons are simple. A sick person is not in any position to ask for assistance, to question the treatment being provided, to assure the medication they have been handed is the correct one, or to guarantee that they understand the instructions they have been given.  If no one is present to say that they are hard of hearing, verbal instructions and questions may be forever lost. Even if a staff person eventually realizes they are not being heard, all of the previous interaction including important questions about history, may have been in vain. Without another person who understands how to go between the patient and the staff, a person may well get sicker because they could not ask for help or did not want to be a bother, could not question the protocols being followed and give benefit of their personal experience with previous treatment, did not recognize the medication they were given or understand the name and function of the medicine when the nurse administered it, or did not understand the follow-up instructions and the rationale for giving them.

4. In the heat of the emotional moment, having siblings helps, even if they are in a different state. Siblings are an asset when dealing with ill parents. Having others with whom to discuss the events and issues is crucial. They help generate additional questions that should be asked. They remind one another of family health history and events that can easily be forgotten. They can share the responsibility for sitting with and encouraging Mom or Dad. Having others to participate in important decisions if a parent is not capable of making those decisions for themselves is invaluable.

5. A Health care Surrogate, an Advance Directive, or a Living Will are not optional. Rightfully, hospitals and health care workers do not want to make decisions for a patient. They especially do not want to make decisions that are inconsistent with the wishes of the patient. They will strongly and clearly recommend what they see to be the best course of care and, with the patient’s permission, they will implement those recommendations up to the limits that the patient sets. If the patient has no person or document setting the limits, all care will be provided as the staff recommends and all of the care they recommend will be provided. Being clear about the limits is only fair to one’s children and essential to one’s care providers.

6. The toll on family caregivers is huge. No matter the outcome of the health care incident, the emotional and physical cost to family caregivers cannot be underestimated, especially if the other elderly parent is one of those caregivers. We most often think about the sick person and how they handled the health care event. It is important that we also think about the family members who participated in the caregiving for Mom or Dad while they were in the hospital and during the caretaking that follows.

My quick Google search for “caregiving” yielded 2,270,000 results. “Family care giving for older adults” yielded 924,000 results. Obviously, this is an area in which interest has exploded. While many of the search results are for some sort of paid service, adding the word “free” at the end still resulted in 514,000 hits. Many communities offer respite care and support groups through their local hospice agencies. Online information and organizations abound. As we baby-boomers age, I fully expect that this will become an industry in itself, with paid and volunteer and not-for-profit organizations.

In the meantime, we are very glad that our elderly parents made it through this round with the health care system. I wonder what your experiences with elder care and our health system have been. Where do you see us heading and what role do you see for behavioral health care in this elder care world?

Please share you comments below.

As reported by Open Minds and American Psychological Association Practice Organization, the lawsuit challenges the rulemaking process and has requested a temporary restraining order to stop the rulemaking process from moving forward. They argue that the Departments of Health and Human Services, Labor and Treasury overstepped their rulemaking authority in how they interpreted the statutory language and violated federal rulemaking procedure in publishing the rule as they did. While the judge denied the temporary restraining order because the law will not be enforced until July 1, 2010, the court will hear the case as presented by the parties to the action.

On May 9, 2010, the NY Times reported that insurance companies and employer groups are also objecting to the rules.

In a suit over the rules, Magellan and other companies said the concept of nonquantitative limits was “boundless and ill defined” and would reach virtually every policy and procedure used to manage mental health benefits.

As most mental health providers can readily attest, the procedures used by insurers and managed care organizations to limit costs and usage of behavioral health services have themselves been “boundless and ill defined”; after all, a treatment plan certainly could not be a valid treatment plan if it is printed on the wrong form. The MBHOs have been innovative in their development of “every policy and procedure used to manage mental health benefits.” Unfortunately, most of that management has consisted of denying or limiting the amount of service provided and placing onerous requirements on providers.

The NYTimes article states that:

One premise of the law is that mental illnesses often have a biological basis and can be treated as effectively as many physical ailments. But insurers say it is impossible to use the same techniques in managing the treatment of colon cancer and schizophrenia, or heart failure and major depression.

What do you think? Is it reasonable to assume that mental illness and addiction can be managed using the same techniques as are used to manage the treatment of cancer or heart disease?

Please share your comments below.

1. The National Council Public Policy Update of April 8, 2010 pointed out an important change in timely filing requirements for Medicare claims:

Requirements of the Patient Protection and Affordable Care Act makes (sic) several changes to the Medicare timely filing requirements. Under the new law, all claims from before Jan. 1, 2010 must be filed by Dec. 31, 2010. Beginning on Jan. 1, 2010, all claims must be filed within one year after the date of service in order to be considered timely.

Sec. 6404 of the law details the requirements. This is a change from the former allowance of 3 calendar years to file a claim. Be clear about this: you now have 1 calendar year after the date of service to file a timely claim for payment for those services.  Now might be a good time to use your billing software to learn which old Medicare claims have not been paid (the claims may have been lost) and if there are any Medicare services that have not been billed. If these are not already three years old, you have only until the end of 2010 to file them, and with services that are new in 2010, you have one calendar year to file a claim for the services.

2. Seth recently posted a message on our User Group about the potential privacy and security problems that can be caused by data left on newer copiers and multifunction machines. NJAMHAA Newswire of May 3, 2010 also commented on the possibility of HIPAA violations that can result from careless use of these machines. Seth’s comments follow:

Now that you finally got all your computer hard drives encrypted and you are feeling pretty smug, here comes another headache — thousands of images containing PHI stored on a hard drive hidden inside other office machines. Take a peek at this investigative report by CBS news:

http://www.youtube.com/watch?v=6pIFUOav2xE

This is a pretty big vulnerability. If you have one of these higher end digital copiers, printers, or multifunction machines and it is stolen — or you neglect to remove or wipe the hard drive before selling or trading it in, you have a reportable security breach. Nobody would be likely to have a list of the patient documents that had been copied over the years, so you
would have to assume that EVERYONE’s protected information was at risk. That means reporting to the Feds, taking out the newspaper ad announcing your negligence, and the rest of the breach notification nightmare!

Apparently all major manufacturers offer security add-ons of some sort. Now would be a good time to inventory your document devices to determine if they contain hard drives and whether you can retrofit appropriate security add-ons to avoid a potentially disastrous situation in the future.

3. The National Council on April 23 published a review of Parity Act implementation that will allow you to determine whether your insurer or the payer with which you are dealing is in compliance with the Parity Act. Is your insurer in compliance with the Parity Act? will help you ask the right questions and provides resources to help you answer the question.

4. On April 22, FierceEMR and other sources reported that hospital-based doctors are now eligible for ARRA incentive payments for meaningful use of certified EHR technology, and that a bill has been introduced by Rep. Patrick Kennedy (D-RI) and Rep. Tim Murphy (R-PA) seeking to include mental health professionals, Community Behavioral Health Organizations (CBHOs), psychiatric hospitals and chemical dependency programs in the ARRA incentives. Time will tell what will fly.

5. And finally, the Mercom Capital HIT Report of May 3 indicated that HHS is seeking comment on the anticipated impact the stricter disclosure reporting requirements included in the HITECH Act will have on providers.

To help guide the Health and Human Services Department in tightening rules for health information privacy, HHS has asked providers, payers and consumers to comment on the benefits and burdens of accounting for the disclosure of protected health information, even if the data is intended for treatment and billing purposes. The HITECH Act called for HHS to strengthen the privacy rule of the Health Insurance Portability and Accountability Act (HIPAA). With the changes, providers, plans and their business partners will have to account for disclosures of patient information contained in an electronic health record, even if the data is for healthcare provision and payment. 

HHS’ Office of Civil Rights (OCR), which oversees health information privacy, published a request for comments in the May 3 Federal Register 
“to inform our regulations under the HITECH Act,” according to the announcement. Under HIPAA, providers and plans currently do not have to report releases of protected data when the disclosures are related to patient treatment, payment and healthcare operations. HHS said in the notice that it will remove the exemption for those disclosures when it involves an electronic health record (EHR).

Needless to say, there is a great deal going on in the world of behavioral health care and health care in general. Please feel free to share news items you discover that might be useful to other readers.

Don’t forget, your comments are always welcome. Please share them below.

In the past week or two I have seen many questions about what the effects of this legislation will be. Behavioral health provider organizations are especially concerned about what the effects will be on mental health and addiction service funding.

One of the most useful resources I have come across was forwarded to the Florida Psychological Association member listserv by Dr. Bob Porter. The Bazelon Center for Mental Health Law has done an excellent job of summarizing the law and its impact on coverage for mental health services. While it will take years for all of the provisions of the new law to be implemented, a Congressional document summarizes some of the immediate effects.

In the private insurance sector, generic requirements of the law have particular impact for those with mental illnesses. In the past, such diagnoses have routinely triggered pre-existing condition clauses in policies. Within the first 6 months, the new law prohibits this discrimination.

1. No discrimination against children with pre-existing conditions.
2. No rescissions based on developing an illness.
3. No lifetime limits on coverage.
4. Tightly regulated annual limits on coverage.

In addition, for those who are currently uninsured, the law mandates:

1. Immediate help for those with pre-existing conditions (an interim high-risk pool).
2. Extending coverage for young people up to their 26th birthday through parents’ insurance.

Since so many who have been diagnosed with mental illnesses or with substance abuse issues have been denied coverage or have had coverage revoked or have reached the limits of their benefits, we should see immediate increased access to behavioral health and addiction services. The ability for parents to keep young adults on their insurance plans until they are 26 years old will assist some of the young people who experience late adolescent onset of serious mental illness or substance abuse conditions. This will allow a period during which their parents will be more able to facilitate transition to some other form of insurance coverage.

The National Council for Community Behavioral Healthcare, the trade association of behavioral health community service providers, hosted a webinar on healthcare reform and its impacts, Healthcare Reform: What Happens Next? Additionally, their Public Policy Update for April 1 gives links to resources as well as information about moving forward from here.

I attended the Council’s webinar this week and was struck by a couple of things. Because the Council primarily represents organizations that provide services in the public sector, their information is generally focused in this direction. For me, there were three take-aways from this session, and they were not all for public sector providers:

1. The Council believes Fee for Service will probably go away in the long run, to be replaced by Case Rates with a Bonus for improvement of the consumer.
2. Behavioral health providers need to position themselves for the long term. Integrated care is likely to be the way of the future and it is best to start to get positioned for that now.
3. Private practices can be competitors in the new system; however, those with deep pockets who can manage the whole range of healthcare services will be better positioned to compete.

Community Behavioral Health Organizations (CHBOs) have been working on these steps for the past couple of years and there will be pilot programs using CBHOs together with Federally Qualified Health Programs to start to provide integrated care. Unless private behavioral health practitioners also start to position themselves to play in the Integrated Care setting, they are likely to get left behind.

Even the American Psychological Association’s advocacy efforts focus on the assurance that mental health services will be part of integrated care. This sounds very much like an integration of mental health services into such settings to me.

What do you think about how the new health care reform law will affect behavioral health services? Do you foresee changes in how care is provided? What changes are you willing to make in your organization in order to assure participation in a reformed health care system? Please enter your comment below. If you don’t see the comment box, just click on the title of the article and then enter you comment at the bottom.

1. Your laptop, with a variety of documents and files containing confidential, protected health information on its hard drive, is stolen from your car, hotel, or disappears while you are traveling.

2. Your office is burglarized and all the desktop computers, as well as a server containing your patient database, are stolen.

I ran across the following set of statistics, or very similar ones, repeatedly, most often on web sites of security companies:

• Every 53 seconds another laptop is stolen in the USA.
• At least 600,000 laptops are stolen each year in the USA. 
• Hardly any (3%) stolen laptops are ever recovered. 
• Laptop computer theft trails only identity theft as the most common crime. 
• Almost half of all data leaks and breaches are the result of lost or stolen portable computers, according to a study by The Identity Theft Resource Center .
• Laptops are the number-one item stolen in San Francisco – San Francisco Police Department.
• The Identity Theft Resouce Center’s recent list of 397 significant data breaches so far for the year of 2009 includes 51 healthcare breaches that compromised almost 9 million records.

Most of the sources of these data are trying to sell a security solution of one sort or another, but the vulnerability of laptops, especially in transit, is obvious. I don’t have any statistics for burglaries of computer systems from offices, but I’ll wager that most of you either know of a victim of such a crime, or have been a victim yourself.

Long before HIPAA, health professionals – especially mental health professionals – had a professional responsibility to safeguard the privacy of their patients/clients and the confidentiality of the personal and clinical information in their custody. HIPAA came along and increased our awareness of the special risks of electronic records and communications, defining Protected Health Information (PHI) at a federal level and providing some rules and guidelines for securing PHI stored or transmitted in electronic form. Now the Health Information Technology for Economic and Clinical Health Act (HITECH) has arrived and adds some pretty sharp teeth to HIPAA’s privacy and security rules.

If you need a push to get you to take privacy and security compliance seriously, consider the following from Section 13402 – Notification In The Case Of Breach. (This section is from HITECH/HIPAA: Notification in the case of breach at lawtechtv.com (a site I would strongly recommend that you visit). The bold italics are mine:

If PHI is secured as per the guidance then providers have a “safe harbor” and the notification requirements are not triggered in case of a breach. Despite the safe harbor, other federal and state PHI laws remain in full force and effect. Any PHI not secured as per the guidance is considered to be unsecured PHI whose breach will trigger the notification requirements. 13402(a): Covered Entities (CE’s) must notify individuals. 
13402(b): Business Associate’s must notify CE’s. 
13402(d): Notification must be no later than 60 days after discovery. 
13402(e): Specific notification methods are required depending on the number of individuals whose PHI was breached. 
13402(f): the notification must contain specific content.
13402(h): unsecured PHI* means PHI that is not secured through: 1) encryption; and/or 2) destruction—as provided by HHS guidance. Methods must render PHI “unusable, unreadable, or indecipherable” to unauthorized individuals (see HIPAA Security Rule  & NIST standards).

If PHI is secured as per the guidance then providers have a “safe harbor” and the notification requirements are not triggered in case of a breach. Despite the safe harbor, other federal and state PHI laws remain in full force and effect. Any PHI not secured as per the guidance is considered to be unsecured PHI whose breach will trigger the notification requirements.

If over 500 individuals’ PHI has been compromised then the media must be notified and the Secretary of HHS as well.

Breach: “the unauthorized acquisition, access, use or disclosure of PHI which compromises the security or privacy of such information, except where an authorized person to whom such information is disclosed would not be able to retain such information.”

Do you really want to have to choose between:

1. Significant civil penalties (between $100 and $50,000 per violation, up to $1.5 million maximum per incident) and …
2. Publishing in the local media a notice of your failure to protect your patients’ private information?

Of course not! Why not take advantage of the explicitly defined safe harbor? If the hard drive of that missing laptop has been encrypted, using appropriate technology, then there is no notification requirement at all! The same technology can be applied to every hard drive in your organization, especially the servers on which the bulk of the PHI resides. There are numerous commercial disk encryption approaches available, as well as free, open-source solutions such as TrueCrypt, that would provide you with the protection you want and owe to your patients, all penalties aside.

My previous post regarding encryption resulted in no reader response whatsoever. Does this information about your notification responsibilities make it more likely that you will move forward with data encryption? If not, why not?

FierceHealthcare, a daily newsletter for health care executives, reported on this trend in its September 30, 2009 edition. The article mentions the research literature that documents the tendency of primary-care physicians to miss the signs of common mental health issues like depression. Overlooking the mental health issues can often complicate both behavioral health and physical health treatment. A diabetic who experiences some debilitating mental health issue may not be able to comply with their required diet and self-care, just as a pregnant woman taking lithium to manage her bipolar disorder faces consequences for her child from her medication. The behavioral health and physical issues are inextricably intertwined.

Behavioral Healthcare online edition of October 1, 2009 reported a SAMHSA-funded study that indicated that general practitioners, not psychiatrists, are the most frequent prescribers of psychotropic medications. This includes pediatricians among the GP category since they usually are the primary care physicians for children.

The FierceHealthcare article identifies the financial and health benefits of the integration of mental health screening and prescribing into primary health care settings. Making sure that mental illness is not overlooked is one way of assuring that patients get the most effective treatment for all of their illnesses.

Since mental health treatment has usually been considered specialist-level care, there is concern among behavioral health providers that such screening and treatment by GPs is not the appropriate care in the right setting. Given how busy primary care providers are, it is highly likely that medications will be prescribed without psychotherapy or other appropriate behavioral interventions.

Health care reform is focused on saving money and providing effective care as efficiently as possible. Some would argue that the primary care provider’s intervention in behavioral health issues is the appropriate, cost-effective way to assure proper diagnosis and treatment. Most mental health providers I know would disagree, perhaps arguing that screening and referral to specialists is the appropriate and most effective way to provide care.

What are your thoughts on this issue? Do you see the possible integration of behavioral health care and primary care as positive for you and your clients? How is this likely to impact the way you currently provide services? What about those of you who already work in primary care settings; is this the ideal way to provide care to all patients, to complicated patients, or to no one at all?

Please let us know your thoughts on this issue. Just click on the title of the article and enter your comments in the box at the bottom of the page.

I do not know what the total attendance at this ICD-10 webinar was, but judging by some of the questions asked, the range of participants was huge. The program was aimed at providers, payers (insurance companies), clearinghouses, application vendors, and anyone else who might be affected by the transition from ICD-9 to ICD-10.

Those of you who have no idea what I am talking about might want to start to get some information about this transition. Federal law and HHS rules require that we move from the ICD-9 and CPT-IV to the ICD-10; the deadline for doing so has been moved to October 1, 2013. It will be very interesting to see if we actually get there in time.

We who work in behavioral health have fairly minimal changes to make. The number of diagnostic codes and procedure codes utilized in mental health claim filing (and upcoming behavioral health EMRs) is minuscule compared to the larger health care arena. Software like ours will require minimal modification; but in the general and specialty medical world, the changes will be massive.

Not only are different diagnostic codes required, but the ICD-10 is also a procedural nosology that most of the rest of the world has been using for many years. It allows a much more finely-grained statement of both diagnoses and procedures utilized. Many believe that data obtained from use of the more specific codes is part of what will allow health care cost savings in the future.

The biggest challenges will involve learning the new code sets and translating our current data into something akin to the new codes. I say ‘something akin to’ because there is not a one-to-one mapping from the ICD-9 and CPT-IV to the ICD-10. In fact, the logic of the two systems is quite different. Reports are that CMS is working on a general equivalence map (GEM) between the two systems. Work will continue on testing and tweaking the GEMs for at least three years after the 2013 deadline.

Private market mapping and consulting also exists. Last week, 3M Health Information Systems announced the release of their own mapping tool in a Healthcare Informatics article. While insurers and clearinghouses and hospital systems may make use of these proprietary tools and consulting services, it is likely that the CMS GEMs will work for many of the rest of us.  

I can feel the chill going up and down the spines of professional coders. In just a few years, they will need to be fluent in another language. My niece just finished a program to be a coder and is now studying for her certification. She will be able to just keep right on studying to be ready by 2013. This is not encouraging for someone who has been coding for 30 years, but for a youngster, being newly fluent in ICD-10 will be a very salable skill.

What preparations do you foresee your organization making to get ready for ICD-10? Have you begun to consider this process? Tell us what you think. Just enter your comment by clicking on the title of this article and typing your thoughts in the box below.

On September 10, 2009, the New York Times published an Op-Ed piece by Michael Pollan in which he discusses the costs of health care in the U.S. Big Food vs. Big Insurance discusses the report of the Centers for Disease Control that chronic illnesses account for 70% of all U.S. deaths. The medical bills of those with chronic diseases result in 75% of the health care spending in the U.S. Pollan argues that some of those chronic diseases…obesity, diabetes, cardiovascular disease…are at least partially the result of America’s terrible diet and overeating. Just helping U.S. residents eat better could result in a dramatic reduction in the costs of health care.

Pollan’s position received some confirmation from a podcast of Science Friday on August 28, 2009. How Cooking Made Us Human focused on the hypothesis that humans evolved effectively and developed larger brains because we started cooking our food. Cooking begins breaking food down before it is eaten, so it is easier to digest. Raw food is harder for the body to digest, so one does not get as much nutritional benefit from the food eaten. The result for human evolution was that we were able to take better advantage of the food we ate by cooking it.

The corollary of this hyothesis is that highly processed foods are a big contributor to obesity because they are too easy to digest. The more processed the food, the easier it is for our bodies to use the caloric content of the food. The result is that those whose diets consist largely of processed foods are also heavier. Raw foods are likely good for some who want to lose weight because the body has to work harder to digest them and does not get all the caloric benefit from the food. One can eat more, feel more full, but consume fewer calories.

Pollan’s point that a change in one aspect of our lives could have huge impact on health care spending got me to wondering…is there a mental health issue that is analogous to food/eating related disorders like obesity, diabetes and heart disease?

According to Open Minds On-Line News for September 14, 2009, mental disorders jumped from fifth place among health expenditures in 1996 to third place in 2006 increasing from $35.2 billion to $57.5 billion. The number of people who sought treatment for mental conditions went from 19.3 billion in 1996 to 36.2 billion people in 2006. While the dollars expended per person for behavioral health care are many fewer than for heart conditions ($1591 vs. $3964), perhaps there is a way for behavioral health providers to dramatically reduce costs of care by addressing a single problem.

According to the U.S. Surgeon General, approximately 20% of the U.S. population experience some sort of mental health disorder in any given year. The best estimate is that 16.4% of the population experience some sort of anxiety disorder ranging from Simple Phobia to Post Traumatic Stress Disorder. A full 82% of those who experience a behavioral health disorder suffer from some sort of anxiety disorder.

Is it possible that education on stress reduction, prevention programs aimed at inoculating the U.S. population against anxiety and early treatment of anxiety disorders might decrease the cost of treating the disorders that do emerge? I have heard public health specialists argue that public education and prevention are the only way we will ever get our health care spending under control. I also have read that there is not yet compelling data to demonstrate that preventive care reduces costs at all.  Perhaps we should just focus our attention on the behavioral aspects of the chronic physical diseases? Or maybe behavioral health providers can work in both arenas and assist in dramatically diminishing the costs of health care across the board.

What do you think about this issue? Where should psychologists, psychiatrists, social workers, mental health counselors, community mental health centers and community behavioral organizations focus their energy? Where will our energies be most effectively spent?

Please enter your comments by clicking on the title of this article and typing your comment into the box below.

Yoga means union. When we think and talk of the postures that are part of the practice of yoga, we are talking about asana, one of the eight limbs of yoga.  While most of the limbs relate to moral and spiritual development, asana and pranayama are very much physical.

Prana means life/breath. Pranayama is one of the eight limbs of yoga focused on the use of breath control to cause relaxation and alteration of mental state. Those of us who have utilized the teaching of progressive relaxation methods as an adjunct to psychotherapy know that the effect of cleansing breath on mental state is real. Diminishing anxiety and depression so a client can take action on life problems is one of the observed benefits of deep breathing, but the effect of breathing deeply is not just on mental state. Fully oxygenating the blood and relaxing the muscles adequately for the blood to circulate properly speeds healing, reduces stress, and increases the acuity of thinking. 

Recently published researchdemonstrates significant emotional and physical benefit from the practice of Iyengar yoga among a group with chronic lower back pain. www.MedicalNewsToday.com quotes the researchers as saying that “low-back pain is the largest category for medical reimbursements in the US, accounting for 34 billion dollars of medical costs every year.” Diminishing the cost of this care could have significant impact on our health care expenditures. This is one case where the use of complementary/alternative medicine can save all of us some bucks while simultaneously increasing the sense of personal responsibility and mastery for the patient.

Iyengar yoga is one of many schools or styles of yoga practice. It focuses on alignment of the body and balance, two crucial requirements for symptom relief. Practitioners utilize props to facilitate the various yoga postures. The use of chairs and blocks and straps to assist getting into and maintaining the positions makes it possible for just about anyone to practice the Iyengar style of yoga. The study found that those who practiced Iyengar yoga had less pain, less disability and less depression than those who did not. Over the longer term, they also used less medication than those who used traditional medical treatment.

My personal experience is that even minimal (twice a week) practice of yoga has had significant effects on my experience. I have chronic lower back pain, neck and shoulder pain. Practice of yoga has resulted in much improved physical and mental well-being.

1. The focus on posture and lengthening of the spine has resulted in a day-to-day, minute-to-minute awareness of how I am holding my body. The  positions in which I put myself in my chair at my desk, standing talking to a colleague, having a telephone conversation all result in muscle tightening. Using proper posture allows the muscles and bones to work as they were designed.
2. My twice a week classes have resulted in considerable strengthening of my muscles. While I bicycle each weekend, my upper body and core muscles get very little workout. The yoga classes take care of that. The core muscles that are crucial to proper alignment of the spine are getting strong enough to do the job adequately.
3. The focus totally on the physical gets me out of my head for two hours a week. The workout tires the muscles getting me into the ideal state to benefit from the deep relaxation at the end of the class.
4. I am gaining control over my physical comfort. I had come to a feeling of helplessness to control my pain. That is gone. I now have a much better sense of what I must do and how I must feel to minimize my pain.

While yoga may not be the ideal method of exercise for everyone, it is a wonderful tool that can be used by many. Why not consider exploring some of the benefits for yourself?

Talk with us about your experience with yoga. Your comments are always welcome.

Just to clarify my statements above: ARRA provided $19 billion in funding for EMRs. $2 billion will be provided to the states to distribute for grants. Community Behavioral Health Organizations (CBHOs) are included in the eligible organizations for these funds. Unfortunately, it appears that this funding is going to be used by the states where they see fit. I have heard from a representative of at least one children’s psychiatric hospital who was told that funding would be used by the state to build Health IT (HIT) infrastructure and data exchange capability. They were informed that providers could get their funds from the incentives. I will be very curious to see how much (if any) of that $2 billion winds up in the hands of providers of any sort.

The larger part of the funding, $17 billion for Medicare and Medicaid incentives, is designed to encourage providers to purchase EMRs and use them to improve the care of their patients. Of the providers eligible to receive these reimbursements, the only behavioral health providers who are eligible are psychiatrists and certain nurse practitioners. They would purchase a system and then receive reimbursements for some or all of what they have spent depending on a variety of complex formulas. If you are a psychiatrist and you do not see Medicaid or Medicare patients, you are not eligible for funding. If you do treat these populations, you will only be able to get funding from one source, Medicare or Medicaid. The amount of reimbursement you can receive depends upon what proportion of your patients are Medicaid or Medicare recipients, along with other complex criteria.

Senator Jay Rockefeller of West Virginia introduced the Health Information Technology Public Utility Act of 2009 in late April. This bill was intended to assure that certain “safety net” providers like rural clinics and mental health providers could also access funds. That bill has not moved. Unless something happens in regulation, it is not likely that psychologists, social workers, mental health counselors, addiction treatment programs, psychiatric hospitals, or community behavioral health service providers are going to benefit from the stimulus funds to help purchase EMRs.

That said, the Health IT Policy Committee did seem to take into account the input they received from the public about the initial attempt at defining “meaningful use of EMRs”. They have drafted a plan that widens definitions, expands time frames, and provides more opportunities for providers to demonstrate that they are using EMRs meaningfully. Their PowerPoint presentation does a good job of summarizing their points. Details can be found in their updated grid and matrix.

1. The primary goal of the definition is to improve the outcomes of healthcare interventions through data capture and sharing and use of advanced clinical processes. They want providers to focus on health outcomes, not on software. HIT is to be a primary aid to healthcare reform, not use of software for the sake of earning incentive money.

2. It is the intention of the committee that there be a phasing in of meaningful use criteria. The public was concerned that if providers could not meet the 2011 criteria in 2011, they would always be behind the train. The committee now recommends that a provider who does not adopt an EMR until 2012 (or 2015) will start at the 2011 criteria and progress from there.

3. Changing work flows to assure the proper use of IT tools is an essential part of the solution. Trying to use CPOE (computerized physician order entry) can actually cause problems if there are not work flow modifications to make sure the process flows smoothly. An unintended consequence of CPOE in at least one study was diminishing of appropriate care because it was inconvenient to enter the order for the care.

4. Since data-based decision support is the real payoff of using an EMR, the committee wants to see this happen sooner, even it if means implementing only one rule in the decision making process.

5. Since engaging patients in their care is crucial to reduction in costs, providing access to an electronic version of their health record needs to be higher priority and come earlier in the process than previously envisioned.

6. Certification of software should be done by more than one body; CCHIT should not be the sole arbiter of which products should be certified.

While the Health IT Policy Committee has now presented their second draft of the “meaningful use” policy, it has until the end of 2009 to finalize the rules. It appears, however, that the direction is set. If you want to get some of the incentive money to help you buy an EMR, you will need to demonstrate that you can use that EMR and can report a variety of metrics to show how your practice is handling a number of issues. So far, none of those metrics are vaguely related to mental health.

Do you expect your organization/practice to be seeking incentive funding to purchase an EMR? How are you proceeding to assure that outcome? Do you think it is important for behavioral health to be included in the adoption of EMRs?

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