Dr. John Bartlett, The Carter Center Mental Health Project

(Music)

Mark Masselli: This is C onversations on Health Care . I’m Mark Masselli.

Margaret Flinter: And I’m Margaret Flinter.

Mark Masselli: Well Margaret, another State of the Union address is in history
books.

Margaret Flinter: And President Obama didn’t focus so much on the Affordable
Care Act last night. That’s beginning to be history but he certainly touched on
many subjects that factor into the health and well - being of the American public.

Mark Masselli: But he did acknowledge the rising cos t of health care driving the
nation’s deficits. He also said he would seek modest changes to Medicare Fund;
perhaps asking wealthier seniors to shoulder more of their own health care
burden.

Margaret Flinter: And he proposed cutting tax payers’ subsidi es to
pharmaceutical companies and also, of course, touched on areas that impact
public health and safety in a huge way; like stricter gun controls and also
facilitating immigration so those living in this country already can get access to
health care and also to education.

Mark Masselli: And also he warned Congress of the dire consequences to the
nation’s faith with the automatic budget cuts going to effect, the cost of goods
st
(inaudible 00:56) which goes into effect in March 1 , if Congress doesn’t co me
up with a new budget agreement.

Margaret Flinter: And a number of programs will be jeopardized if that happens,
Mark. Certainly thousands of research grants currently underway at the National
Institutes of Health; a mental health block grant that sup ports behavioral health
services for some 400,000 Americans. These are things that, if impacted, could
lead to really dire consequences.

Mark Masselli: Our guest today has been in the trenches of the behavioral health
care and he is now working towards a goal of putting more behavioral health
screening and treatment in primary care setting.

Margaret Flinter: Dr. John Bartlett is the senior project advisor for the Primary
Care Initiative at the Carter Center’s mental health program.

Mark Masselli: The Carter Center started 30 years ago by President Jimmy
Carter and first lady, Rosalynn Carter; long time champions of mental health care
in the health care, something we really believe in here in our own practice in
Connecticut.

Margaret Flinter: The C arters, as all of us in primary care know how essential it
is to treat the whole patient’s needs and poor mental health underlie so many
health problems, a huge public health issue and still grossly undertreated.

Mark Masselli: We’ll also hear from factcheck.org’s Lori Robertson.

Margaret Flinter: And no matter what the topic, you can hear all of our shows by
Googling CHC Radio and as always, if you have comments please email us at
CHCradio.com or find us on Facebook or Twitter, because we love to hear from
you.

Mark Masselli: We’ll get to our interview with Dr. Bartlett in just a moment but
first, here is our producer Marianne O’Hare, with this week’s headline news.

(Music)

Marianne O’Hare: I’m Marianne O’Hare, with these health care headlines. The
President’s State of the Union address focused more on job creation and building
the economy than it did on health reform. The President warning this week
though, he wo uldn’t agree to raising the eligibility requirement age for Medicare
to 67, as some have suggested.

st
He warned Congress last week that allowing the sequester on March 1 would
seriously jeopardize several key areas in health care; 12,000 research grants
would go away, affecting leading research under way at the National Institutes of
Health and close to 400,000 Americans receiving assistance with the Mental
Health Block Grant would see that support disappear if the automatic spending
cuts were allowed to go into effect. GOP members of Congress are demanding
st
more spending cuts before they’ll vote to extend the budget past the March 1
deadline.

Meanwhile the Congressional Budget Office released a report this week that
showed a sharp slowdown in health c are cost increases and is helping to narrow
the budget deficit. Medicare and Medicaid spending a rate that’s about 15%
below what was projected three years ago. At least that rate is on target for 2020
at 15% lower. The report showed that overall health care spending had grown at
the lowest rate in decades for a fourth consecutive years. Experts are still not
certain what percentage of this shift is due to fewer people seeking health care in
a tough economy.

And from the Apple a Day file, get another st udy out connecting physical fi tness
in middle age and fighting dementia; a 24 - year long study compared middle age
patients on a treadmill test. Those in better at the middle age mark had a 36%
lower rate of dementia later on. I’m Marianne O’Hare with the se healthcare
headlines.

(Music)

Mark Masselli: We’re speaking today with Dr. John Bartlett, Senior Project
Director for the Primary Care Initiative at the Carter Center’s Mental Health
Program. The Carter Center founded 30 years ago by former Presiden t Jimmy
Carter and former first lady Rosalynn Carter is a non - profit organization
dedicated to promoting peace and better health throughout the world. Dr. Bartlett
coordinates the activities of the primary care initiative which seeks to facilitate
better treatment of mental health and substance abuse in the primary care
setting.

Dr. Bartlett earned his medical degree from Yale and completed his psychiatry
residency at UCLA Medical Center. He is a former vice - president for Cigna
Mental Health and is a R obert Wood Johnson clinical scholar. Dr. Bartlett,
welcome to Conversations on Health Care.

Dr. John Bartlett: Thank you so much, Mark. Thanks for the opportunity.

Mark Masselli: John, you’ve logged a few decades in the area of behavioral
health and substance abuse and it’s estimated that six out of ten Americans
visiting a primary care provider are suffering from some sort of behavioral health
or addiction issue, but that often those issues do not get recognized or
adequately addressed in the primary care setting. How much of an effect is this
really having on people’s health care in this country?

Dr. John Bartlett: That’s an excellent question Mark and frankly, one that gets
right to the heart of what we see as the opportunity here. State of the heart
epidemiological studies; I mean studies that look at the incidents and prevalence
of diseases in a population show that in any given year in this country, about
25% of the general population meet current diagnostic criteria for mental health
or subst ance abuse issue. Now, that doesn’t mean that they are all diagnosed.
It certainly doesn’t mean that they get treated but they do meet diagnostic
criteria, so we know that issues like depression and anxiety and addiction are
widespread on the general pop ulation.

We also know that these conditions are associated with high levels of both
morbidity and disability. In fact, in the developed world; countries like the United
States, Canada, Western Europe depression is the leading cause of disability
adjusted life years. In other words, it carries the greatest burden of disease; far
greater than something like heart disease. They are prevalent, they cause a lot
of disability, a lot of morbidity and most importantly in the context of what’s going
on in this c ountry right now with our tremendous budgetary and financial issues,
there is a tremendous amount of expense associated with the co - occurrence of a
chronic medical condition like heart disease or diabetes, and depression or
anxiety. In the debates around the Affordable Care Act that show that up to 15%

and even 20% of cost associated with chronic medical conditions could be
directly related to co - morbid mental illness and/or substance abuse.

If you throw in behavioral issues like lifestyle choices, smokin g, lack of exercise ,
obesity; you start to see the scope of the issue and in fact, current studies from
major leading managed care companies show that about six in ten patients who
show up in a primary care doctors have some behavioral component; either a
condition like depression or anxiety or a lifestyle problem as part of their
presentation. So it’s really a huge issue.

Margaret Flinter: John, tell us more about the Primary Care Initiative itself at the
Carter Center’s Mental Health Program and how is this initiative moving us
forward in ameliorating this problem of lack of access to mental health and
addiction services and let me add the word “effective” to that as well, lack of
access to effective mental health and addiction services.

Mr. John Bartl ett: Traditionally, the focus of mental health and addiction policy
has been on those most severely impacted; people with what’s called severe and
persistent mental illness, people who are addicted and need abstinence based
treatment, etc. and that has re ally been a tremendous focus for the last 30 years
or so, and frankly successful because we add things like the institution of parity
with the Mental Health and Addiction Parity Act, but beginning with the release of
David Satcher’s, when he was the Surgeo n General, he released a report on
mental health in America in 1999 and that really started a growing recognition
that there was a hidden crisis about accessing appropriate and effective mental
health care.

When I say hidden, it occurred in people who w ere seeing doctors. They weren’t
seeing specialists; they were seeing primary care doctors or general medical
doctors or medical specialists, whatever. So that report really highlighted this;
there is a large associated behavioral component to the presen tation of many,
many people. So depression, problem drinking or drugging and unhealthy
lifestyle choice, etc. A lot of the work has been done in the area of depression
for obvious reasons; it’s an important condition. It’s one that we have treatments
fo r and treatments frankly that can be implemented in the primary care sector.

Over 50% of the people who get treated for depression receive their treatment
only in the primary care setting. Under routine approaches to these patients,
only 30% show clinica lly significant improvement. Yet at the same time, for many
of the past several years anti - depressant medications have been among the
most widely prescribed classes of medications in the country. In 2005 in fact,
they were the most widely prescribed clas s of medication. So what we have is
we have a tremendous amount of time, energy, money going into the treatment
of a condition like depression and yet, only a very low clinically significant
response rate, so we’re literally wasting tens of millions of do llars on not
ineffective treatments but ineffective courses of treatment.

The medications have all gone through FDA review but it’s how they are being
prescribed, how they are being followed; that is not going on in the primary care
setting, not because p rimary care doctors are bad people they are busy people.
The average primary care visit lasts somewhere between 12 and 15 minutes . In
that 12 to 15 minutes, primary care doctor has to deal with three or four chronic
medical issues, as well as a depressio n/anxiety problem, drinking, drugging, etc.
Depression sort of comes usually at the end; “How is your sleep? Are you
feeling better?” “Yes,” etc. It’s not adequate follow - up and so in fact, what we
find is that response rates are not very good in the p rimary care setting. We
really have a lot of work to do in terms of becoming more scientific about how we
not just prescribe medications but more importantly how we follow treatment
response.

Mark Masselli: John, you’ve got a great perch at the Carter C enter where you
work with multiple partners in the pursuit of eradicating disease globally but also
providing better health care to Americans here at home. I wonder if the
conversation that you were just having now came out of the work that you had
done a t the Health Education Summit where you jointly held the summit with the
American College of Physicians and issued a paper, The 5 Prescription for
Ensuring the Future of Primary Care .

Perhaps you were telling us part of that already or if not, can you t ell us about the
both the collaboration with the College of Physicians and what are you
prescribing for primary care practices?

Dr. John Bartlett: We have a very active and collaborative relationship with the
primary care specialties; the American Colleg e of Physicians, the American
Academy of Family Physicians, etc., and actually what I was talking about did
lead to the Health Education Summit market, it actually came out of an earlier
summit meeting that we had here, called the Medical Home Summit which
happened in the summer of 2009 and at that summit we brought together about
50 people from the fields of primary care, behavioral care. So the question that
we tried to address at the Medical Home Summit was could the patient centered
medical home be use d as a platform to scale up evidence based approaches to
integrated care? Out of that meeting came a couple of recommendations. One
was that we work closely with the accrediting organizations, like the National
Committee on Quality Assurance to make sure that whatever standards were
developed f or accrediting patient centered medical homes focused very clearly
and explicitly on the importance of recognizing, screening and addressing
behavioral health issues in the primary care and that was an effort that w as
successful with the release of the new, revised standards for the patient centered
medical home about a year and a half ago.

The other thing that was, the recommendation that came out of the Medical
Home Summit was that we do something to address the e ducation of health

professions. That led to the Health Education Summit which we co - sponsored
with the American College of Physicians. At that summit, we tried to address the
question of are we training the health profession students of today to work
eff iciently and effectively in the health delivery system of tomorrow.

Margaret Flinter: Well John, we look at this pipeline; where is this workforce
coming from and as we look at the early implementation of elements of the
Affordable Care Act and then more of it coming in January 2014, how is the
Affordable Care Act speaking to the issue of workforce size and development,
education and training?

Dr. John Bartlett: In the context of integrated care Margaret, it’s doing some
things well. I mean it certainl y has made a commitment to increase the size and
impact of the primary care workforce in this country. So there are provisions
within the Affordable Care Act that in crease the reimbursement to primary care
physicians which have traditionally been underfun ded like psychiatrists and other
mental health clinicians have traditionally been underfunded.

In terms of promoting integrated care, it’s exactly those initiatives that you just
spoke about; the patient centered medical home demonstration projects and th e
accountable care organization demonstration projects that really are advancing
integrated care as well. I mean, it’s my belief that when you start moving into an
environment like an accountable care organization where a single entity is
responsible for both the clinical and the financial results, if you do not
aggressively screen for and address behavioral health issues like depression and
problem drinking, drugging you’ll never be able to meet the financial or clinical
goals. So, that’s really the next generation of hope for integrated care in a way.
In terms of producing a workforce that is trained to work in that direction, there is
still a lot that needs to be done frankly. There is a great emphasis now on
teaching team based work to health profess ion students but in terms of focusing
that on the role of the behavioral specialist within the team and the recognition on
the part of primary care providers that behavioral health issues are a major part
of what they are going to be seeing in their primar y care practice. There is still a
lot of work that needs to be done.

Mark Masselli: We’re speaking today with Dr. John Bartlett, senior project
director for the Primary Care Initiative at the Carter Center’s Mental Health
Program which is seeking to tra in primary care clinicians to better identify and
treat behavioral health and addiction issues in the primary care setting. Now the
Carter Center relies a lot on the idea of team work to achieve its goals and it’s
worked pretty well for the organization, but you say that teaching team work is an
essential element of medical training of the future. Explain to us how you see
team work model evolving in the emerging area of medicine.

Dr. John Bartlett: I think that the primary care is a team based sport, f rankly.
People come in with incredibly complex presentations and because of the current

emphasis on efficiency in the primary care setting, the care of individuals happen
in a team based environment. In 12 to 15 minutes, no single individual can
address appropriately all of the issues that people bring into a primary care visit.
It doesn’t mean they have to do it all themselves but it does mean that in a
comprehensive, integrated, effective primary care environment all of the services
need to be provided and you can only do that through a team based approach.

Now, the interesting thing; actually you pointed it out earlier that I spent a number
of years as senior vice - president and corporate medical director for Cigna
Behavioral Health Care. I worked in industry with companies like General
Electric and Martin Mar ietta and IBM, and the amount of money and resources
that corporate America puts into training teams to be high functioning teams is
huge, it’s literally tens of millions of dollars. We put no mo ney into that in health
care. When I graduated from my internship; I was a medical intern at Jefferson
University in Philadelphia, I got in my car, I drove to California where two weeks
later I was the leader of a treatment team at UCLA. I knew nothing m ore about
psychiatry than I had two weeks ago when I was a medical intern but I was the
team leader. So, we don’t do a very good job of training people to be more
effective team members. We need to pay attention to that.

Margaret Flinter: I want to may be move one degree away from what we think of
as the classic primary care office and think about innovati on; maybe one step
when we’re still within what we would think of as general domains of primary care
and ask you to comment on your work in this area, your thinking about how it
contributes, and I’m thinking specifically of things like school based health
centers.

Dr. John Bartlett: One of the interesting things that we are doing here is that
we’ve actually sort of moved the concept of integration beyo nd the context of
integrating primary care and behavioral care. We’re actually moving into
integrating the medical and behavioral delivery system into the greater
community. One of the things that I’m involved now is working with faith based
communities around the country to move behavioral health screening out of the
health care environment into the faith based environment through pastoral
screening and counseling frankly.

A couple of years ago, we co - facilitated a meeting with the National Center for
Primary Care at Morehouse School of Medicine where we brought together a
group of individuals from organizations such as yours who have moved pretty far
down the path towards patient centered medical homes, and then we invited a
whole bunch of other peopl e who were interested but had not made that
commitment yet. And it was funny, all the people who would sit there and say
like, “We are really interested in this but we need to get paid for it.” All the early
adopters said, “Don’t worry about that, it wil l more than pay for itself, it’s the right
thing to do.” Interestingly enough, when you start moving this into the pastoral
environment, they just focused on that “it’s the right thing to do,” and so we’re

very interested in using this mobilization of the faith based community. We could
just as easily look at mobilizing the business community, as you talked about.
It’s using these other channels to bring screening and early interventions out into
the community in an effort to improve overall community he alth that we’re getting
very interested in at this point.

Mark Masselli: We’ve been speaking today with Dr. John Bartlett, senior project
director for the Primary Care Initiative at the Carter Center Mental Health
Program, the Carter Center founded 30 ye ars ago by former President Jimmy
Carter and first lady Rosalynn Carter. You can learn more about all of the
exciting work that’s being done at the Center by going to cartercenter.org . Dr.
Bartlett, thank you s o much for joining us today on Conversations on Health
Care.

Dr. John Bartlett: Thank you so much, Mark and Margaret.

(Music)

Mark Masselli: At Conversations on Health Care, we want our audience to be
truly in the know when it comes to the facts about health care reform and policy.
Lori Robertson is an award - winning j ournalist and managing editor of
factcheck.org , a non - partisan, non - profit consumer advocate for voters that aim
to reduce the level of deception in US politics. Lori, what have you got for us this
week?

Lori Robertson: Well Mark and Margaret, the contraception mandate is back in
the news. Last year, the Obama administration announced that most employers
would have to offer insurance that covers contraception for free. Churches were
exempt but not other religious organizations, such as hospitals and universities,
and the administration later amended it saying that religious groups wouldn’t
have to provide free birth control coverage but instead the insurance companies
would do so. Well, now the Administration has proposed that religious groups
could offer plans that don’t cover birth control, and then the health insurance
companies would automatically issue employees a separate policy that only
covers birth control, at no cost.

The Administration has argued that free contraception is cost - neutral as it
prevents unplanned pregnancies. Critics say premiums would go up. Who is
right? Several studies have been conducted on this topic but the re sults are
conflicting and inconclusive. In Hawaii, for example, where there is a
contraception mandate a study concluded that it didn’t increase premiums.
Studies in Pennsylvania and Kentucky simply couldn’t determine if free
contraception ultimately pro duced savings and a Texas study said, free birth
control wouldn’t generate enough savings. The reason, said that study, women
would buy contraception on their own even if they weren’t getting it for free. We
found there wasn’t clear evidence to conclude that it’s cost - neutral or that it

would increase cost. And that’s my fact check for this week. I am Lori
Robertson, managing editor of factcheck.org .

Margaret Flinter: F actcheck.org is committed to factual accuracy from the
country’s major political players and is a project of the Annenberg Public Policy
Center at the University of Pennsylvania. If you have a fact that you’d liked
check, email us at CHCradio.com . We’ll have factcheck.org ’s Lori Robertson
check it out for you, here on Conversations on Health Care.

(Music)

Mark Masselli: Each week, Conversations highlights a bright idea a bout how to
make wellness a part of our community’s and everyday lives. It’s no secret that
the nation’s kids are sedentarian, overweight and the problem isn’t being
remedied in many of the nation’s elementary and middle schools, where there is
little or no structured physical education.

The National Foundation on Fitness, Sports and Nutrition has partnered with
other organizations to find tools that will improve the physical health of students
in schools across America. There is a new Phys Ed partner in town, enter a
popular interactive video game, Dance Dance Revolution; a game that engages
players in real physical activity with energetic music and visuals on a computer
monitor to keep participants moving for sustained periods.

Rich Killingsworth : Dan ce is one of the things that resonates with children and it
has really advanced two components here; using a gaming context and
promoting more physical activity through either a physical education program or
through recess time, or through those break peri ods where children can access
this at school or other youth serving organizations.

Mark Masselli: Rich Killingsworth is the Foundation’s former director and says
their congressionally chartered mission was to create private sector partnerships
that wil l enable all Americans and especially American children to lead healthier
lives.

Rich Killingsworth: So we’re looking at where children and others are spending
their time and when you think about how we spend our time during the day, six to
eight hours of our day is spent behind a screen ; whether that’s a computer
screen or a TV screen. Using that moment and for children to create more
activity and something that resonates with them; gaming is a powerful tool, it’s a
social tool and if we can build in ways for them be active through that it’s going to
be sustainable. It’s going to resonate with them, they are going to be attracted to
it and use it as part of their cultural way of connecting.

Mark Masselli: So they formed a partnership with DDR creato rs Konami to
create Dance Dance Revolution – Classroom Edition. The PC - run program is

user friendly, led by a teacher and each kid has a dance pad that tracks their
BMI, their calories burned and their physical output during this session.

Rich Killingswo rth: It gives them a baseline for where they are and then how
they are improving, and that culturally is very different from where we were. Kids
are more oriented to numbers now and how progress is important in their social
network.

Mark Masselli: Kill ingsworth says that the pilot programs in a number of schools
have been extremely promising. Kids are already familiar with the game, have
fun engaging in it and there is a competitive element as well that spurs the kids
on. The partnership also includes the American Diabetes Association, the
American Alliance for Health, Physical Education, Recreation and Dance. Dance
Dance Revolution – Classroom Edition; a fun, familiar and fast - paced video
game being used in a simple school setting to significantly in crease daily
movement and improve physical fitness. Now, that’s a bright idea.

(Music)

Margaret Flinter: This is Conversation on Health Care. I am Margaret Flinter.

Mark Masselli: And I am Mark Masselli, peace and health.

Conversations on Health C are, broadcast from the campus of WESU at
Wesleyan University, streaming live wesufm.org and brought to you by the
Community Health Center .