We had a lot of questions, which I was taking notes of. Some of them were in duplicates, so I'm just trying to summarize. But going back to the top of the presentation, there were some questions regarding the estimate of the $12,000 to $15,000 per year, and what exactly that includes. Is that only including CSC services? Does it include hospitalization dates? Does it include indirect supervision, et cetera? So just to either of you, can you clarify a little bit on that? That was the figure that we used from the Rosenhex study includes all of those services. I'm not 100% clear about supervision, but it was all medical services, psychiatric as well as general medical and pharmacy. One of the points that they made in the cost effectiveness analysis was they were using an on-patent medication as the preferred medication at the time. That medication has subsequently become generic and is much less expensive, and they felt that really the small difference between the RAISE program and ordinary care would be greatly reduced with the use of this generic medication. But it did include all. So it was comprehensive of costs and included indirect. I'm not sure about supervision, which probably would be in the indirect. Thank you. And there was a question as well about any updates on information regarding the identification of a billing or procedural code at the national level for this work. That's what our colleagues at the Meadows Institute and some of us on the call as well had a marginally small role in it. There is a recommended, and Doug, you may have to help me out here, a recommended HCPCS code that covers this type of a service as an existing code. And the strategy was to, if at all possible, use an existing code. Because if you get a code created, it can be an arduous process. And it was the conclusion of the Meadows group, which was a broadly representative group. It wasn't just people from the Meadows Institute. Doug and I both had roles on it, although not significant roles. At least not mine. Doug's maybe more significant than mine. That this was, in fact, a code that's viable. Now that's, excuse me, going to be probably tested in Illinois. Because I think they are very grateful to have had that thinking done by our colleagues in Texas. And we'll see. Stay tuned. We'll hear more about the codes that are going to be used in Illinois soon, as they are now in that stage of negotiation. Doug, did you want to add something? Yeah. The so-called HCPCS, that's a way to try to pronounce a long name, which stands for HCPCS code, which is Health Care Common Procedure Coding System. And this is already in existence for dealing with forms of medical care that involve things which are not covered by CPT codes. So for instance, and hospitalization codes. So this would include, for instance, rehabilitation costs following a myocardial infarction. That's not care done in the cardiologist's office. It's not your care in the hospital, in the ICU. But it has to do with rehabilitation, physical therapy, dietary support, and other aspects. So things that go into these things, which are really important to outcomes, if you don't do those things, the surgeon's cases don't survive. You need to do these things to actually make care work. But they tend not to be covered by typical chief of service CPT codes. So these are all inclusive, basically cost-based codes. But they've not really been used in mental health. And so the recommendation from the Meadows Institute was to look into this. So this is still a work in progress. I'm not aware of any place that's actually doing this yet. But it's encouraging to think that there are approaches to this. And I should say, elsewhere around the world of medicine, you see care bundles increasingly used for post-op care or treating a complex, multi-component treatment for different disorders. So we're not alone in this. This is gradually, I think, coming into value-based health care approaches being implemented in various places. But back to your question, specific codes at this point, and I'd say still a work in progress. Great. Thank you. And then you talked about the phenomenal work that's been done in Illinois. Curious as to why was supported education and employment not included within that, and how will that be covered? And then an additional question on that is, once somebody's transitioned out of CSC, what will happen to that individual in terms of their coverage for other services post-CSC? Those are two parts of that. It was just they couldn't negotiate enough to get it in. It was seen not as, and this is a typical problem, that these vocational-type services were not seen as medical services. And although, when you talk to anyone who runs a CSC program, they'll tell you that support employment, support education are critically important elements of the program to keep people sort of on their life course, there still are boundary disputes about what should be covered as an educational service, a rehab, folk rehab service versus a medical service. And they just lost that battle in Pennsylvania, and they were very disappointed, by the way. In Pennsylvania, they had similar findings. I'm hoping that given the strength of the data, we can start to get out some of our categorical thinking about what's needed. The service, I think, will be paid for in Illinois with state general fund revenues, perhaps with collaboration with folk rehab. To be honest with you, I can't remember the specific strategy, but we could certainly find that out for you if that is important. And I don't know about transition issues. That's probably going to be part of the negotiation. We said during the presentation that one of the issues is that there are variable intensity of services throughout the average sort of two-year duration of services, and there's some discussion about whether or not there should be sort of stepped down rates or stepped up rates, depending upon the needs of service providers. That is an unsettled question, and there are a lot of unsettled questions about transitions from care and some real concerns about how that might best be handled. But right now, I think many of those are still quite open. No, I'd say I'm optimistic that history will go in a favorable direction at this point, because right now, we have to negotiate with organizations that really have an incentive to try to keep their immediate short-term costs as low as possible. There's no mechanism to factor in whether even intermediate care costs, not just going into the next year or so, whether we're going to decrease healthcare costs utilizationally, decrease other costs to society, whether that will get factored in. But at this point, you cannot put all those things on the same ledger sheet and come up with an argument in either the public sector or private sector. But on the other hand, there's more and more recognition, we all know this, of the societal factors that contribute to illness outcomes, and that if you want to deal with things like the high utilizers of medical services in the general hospital, they're showing up in your ER all the time with their diabetes, hypertension, obesity, and so on, who, by the way, likely have high ACEs scores and other complexities in their lives. We have to deal with the whole package, and we don't have a way to account for the cost of dealing with the whole package and the outcomes of taking that approach. I think it's a matter of time, and it will probably require having a more comprehensive medical system of one kind or another before that obvious arithmetic starts to make sense. Great. Thank you. And just to direct people that Mark Fagan has also added some information in the chat box on this as well, Mark's from Thresholds in Chicago. I'm glad Mark was on. I've not seen the participants, but Mark knows everything there is to know about what's happening in the world. And we just have a couple of minutes left, so one final question. For the people who are attending today, who may be in programs or at state level, based on the work that you've been involved with, with what you've been seeing happening nationally in different states and the successes, what are some sort of actionable steps or advice that you have to help people move forward? Very big question when you don't know the specific details of each of the individuals on the call, but just what are some successful steps that you've seen that people might be able to take to move this forward within their own areas? I think you have to build local consensus and support, probably starting with families of people who are ill, and then reach out to people in positions of decision-making. Mental illness is not an uncommon reality, to say the least, and so you'll find people who have struggled with these things, who might be state legislators, people in politics, people in business, and interested in what the employee benefits are in large companies or small companies. So I think you have to start sort of at the grassroots level and building a consensus of support. And I think coming back to the fundamental facts and kind of trying to gently but persistently hammer these through. You don't see people every day with a psychotic disorder, but there are many of them out there. People with serious and persistent mental illness, by some estimates, are maybe as much as 7% or 8% of the population, or as low as 2%, but even that's a lot of people. And they cost a lot, they have miserable lives, they incur all sorts of grief and difficulty for their families, and yet we have the capacity to treat them much more effectively than we generally do. We used fragmented pieces of what might work, rather than putting together all the parts. I should also point to a whole other work area of collaborative, comprehensive care in the VA system. Work under Mark Bauer, a psychiatrist who was at Brown, now at Harvard, showing that even with established illness, not early psychotic disorders, but people who have been ill for quite some time, you can get markedly better outcomes with the same dollars, without spending more money. I think in the earlier phases, we may see these cost savings, but at the most pessimistic, we could do way, way better with the dollars we're already spending. So I think it's a matter of building the consensus, making people aware that there's something you can do. I think in the time of the training of most of us probably listening, we've been told that these are untreatable illnesses. We've been told that schizophrenia is a, quote, death sentence, or a life sentence. They're really pessimistic, miserable language, which we now know not to necessarily be true. Some of these things can very much be treated. And even if you don't fully eradicate the illness, you can bend the trajectory of somebody's function and quality of life in a very favorable direction. And it's really negligent for us as a society not to do this. Thank you so much. Yeah. Doug hit some really important points, Kate, and I'm aware that we're up against 2.30. Our hope was that this little issue brief might be used by clinicians or other advocates to sort of move the conversation forward, demonstrating the possibility for coverage. So hopefully that'll be part of the strategy as well. Wonderful. Thank you so much. Thanks to you both for a fantastic presentation.

CSC services estimate

medical services

psychiatric care

generic medication

RAISE program