Friday, May 3, 2013

Greyhound Therapy - suddenly wrong?

Without any disrespect to the famous long haul bus company, I wanted to comment on this story posted from the APA's Facebook feed.  It is a story about a man, James Brown who was discharged unchanged from a psychiatric hospital in the state of Nevada and sent to California via bus with minimal resources.  That was the discharge plan.  Watch the actual clip to see what happened and watch the concerned discussion by the public official in this case.  Diane Sawyer, et al were outraged.  How could this possibly happen?  How often does this happen?  There was a happy ending to this story but how often does it go horribly wrong?

When I looked at this clip I was amazed for a couple of reasons.  First off, it was on the APA's Facebook feed with a comment by the Medical Director.  Without going into all of the details that I have posted so far on this blog, I will say that it is about time and leave it at that.  The fact that nothing has been said to this point is also reflected in my second point and that is -  this has been going on for over 20 years!  Every place in this country with a major psychiatric hospital has been the recipient or point of origin for discharges by bus to another state.  It is so common that I used to refer to it as Greyhound Therapy with my coworkers and everybody knew exactly what I was talking about.

At first blush putting somebody with a severe mental illness on a bus and sending them to another state - sometimes across a number of states seems inhumane.  In some cases, the person himself may insist but if we are talking about the instance where the person is mentally ill and cannot care for themselves - I agree completely.  It is inhumane and not really ethical from the standpoint of a physician.  So how does it occur?

It basically occurs by taking a business approach to psychiatry.  Rationing and cost center management coalesce into the perfect mechanism to get people out of psychiatric hospitals when they are at their most vulnerable.  I have posted many times the concept of getting people out of the hospital before the hospital loses money on a DRG payment.  That is generally within 3 - 5 days.  That period of time is well below any acceptable time period necessary for the evaluation or treatment of severe psychiatric problems.  Everyone agrees that  hospital treatment like outpatient treatment means treating people with medications and in hospitals the medications are generally added faster and at much larger doses than in outpatient settings.   Five days does not allow for any changes if there are side effects or inadequate treatment response or comorbid medical complications that may crop up.  So doctors don't want to use this approach.  Who does?

The main drivers are managed care companies and the government agencies that promote these tactics.   So the psychiatrist doesn't want to discharge the patient in 5 days - get a managed care reviewer to say that the hospital stay is no longer "medically necessary" and will not be paid for.  If the attending psychiatrist doesn't like that decision - he or she can appeal it to another reviewer within the same company.  How do you think that will turn out?  Of course you can always appeal to the state - right?  The state has managed care rights embedded in their statutes.  The appeal goes through a commission that is often staffed by insurance industry insiders and they are not there to advocate for patients or their physicians.  In the case of psychiatrists who are unfortunate enough to work for managed care companies, they may find their discharge decisions commandeered by case managers and a medical director whose only jobs are to get people out of the hospital as soon as possible.  Disagree with them and you might hear that the medical director will come down and take over discharging the patient.  Or you might find yourself fighting a never ending series of political battles for not being a "team player."  The discharge team may decide to do an end run around you entirely and that could involve putting somebody on a bus.

What about the psychiatrists working in these settings?  Why don't they ever speak up?  It should be obvious from the preceding paragraph that it could result in getting fired or forced out in one way or another.  Every organization these days has policies that stifle disclosure from physicians working in those companies.  All of the communication needs to go though an administrator who has the company's best interest at heart.  The interest of the patient, the physician, and the physician-patient relationship is not a priority.  Making money is the priority or in the case of health care, being "cost-effective".

We have a perfectly corrupted system of hospital care for people with severe mental illnesses.  Businesses and governments can essentially do what they want.   Many of these settings are so miserable that good psychiatrists avoid them.  Patients churn in and out often with no changes or changes that are so abrupt that they are immediately rehospitalized. 

There is a solution that can have immediate impact and potentially lead to reform.  I applaud James Brown in this case for disclosing what happened to him and elegantly stating what he was deprived of.  On the other hand, nobody should have to forfeit their confidentiality and talk about what continues to be a stigmatizing illness just because business friendly systems predictably fail to provide quality medical care and marginalize medical decisions.  A whistleblower statute that protects any psychiatrist who reports that their patient was discharged against their recommendations and given a bus ticket is a quick solution.  It should also apply when a managed care company is insisting that an unstable patient be discharged when they remain at high risk or have not been evaluated or treated.  The ABC story here suggests that these discharged patients may be "dangerous to themselves or others".  In fact, the majority of these cases are very vulnerable people who need help and protection.  That help and protection is not coming from a government set up to protect the managed care industry and those forces that ration care for the mentally ill.

George Dawson, MD, DFAPA

ABC News.  Man with Psychosis Recalls Nevada 'Patient Dumping'.

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