Saturday, September 21, 2013

American Psychosis - The Final Take

I finished reading E. Fuller Torrey's recently released book American Psychosis - How the Federal Government Destroyed the Mental Illness Treatment System .  I recommended it on the basis of a a quick initial read of a brief section on managed care but can provide additional details at this time.  I will start with the conclusion.  Criticizing an expensive, fragmented, and poorly conceived system of care for severe mental illness is a fairly easy task for any psychiatrist who tries to provide care for the target population of people with schizophrenia, bipolar disorder and severe mood disorders. This book concentrates many of the references about deinstitutionalization, incarceration of the mentally ill, victimization of the mentally ill, and aggression and violence by the mentally ill in one place.  In the conclusion Dr. Torrey also recommends some 10 potential solutions to the problems and more importantly suggests the some of these need to be implemented on a small scale rather system wide.  

I am sure that Dr. Torrey and the publisher of this book would not be very happy if I put all 10 of his proposed solutions on this blog, so I am going to focus on one that is consistent with my initial post and one of the major themes of this blog:

"For profit funding of of public mental illness services has been tried and it does not work." 

This is the real experience of anyone who has worked in psychiatric acute care and by that I mean the hospital in your community where people are brought in by the police on emergency holds.  Even in that setting there are levels of acuity.  In a metropolitan area there may be 8 or 10 psychiatric inpatient units but only one or two of them will accept patients with high levels of aggression or suicidal behavior.  In an ideal world these would be units where there are staff with high levels of expertise in treating these severe conditions, but the reality is that economic considerations are at the top of the list.  There needs to be adequate staffing for close supervision and the staff have to be able to deal with high levels of aggression toward self or others.  There also needs to be expertise in recognizing and treating alcohol and drug intoxication and withdrawal states.  There is usually minimal attention paid to the therapeutic aspects of the environment.

When I first started working in that environment it was the late 1980s.  I had just completed a three year stint as the medical director of a very good community mental health clinic that offered case management and Assertive Community Treatment.  I was well trained in community psychiatry at the University of Wisconsin Psychiatry Department and it was good to actually practice it with a team of highly motivated people.  
The first months on the inpatient unit resulted in several "denials" by insurance company intermediaries functioning to ration care.  Keep in mind that all of these patients were in the highest acuity unit in the hospital, had problems with suicidal and aggressive behavior, and many needed detoxification. The rationale of the "peer reviewers" was the the patient did not require acute care or the care could be provided at a less intensive facility.  Apart from county detox facilities that had policies against admitting suicidal or aggressive patients - no less intensive facilities existed.

When you are in that environment trying to provide care, it is pretty obvious that this peer review process is basically an insurance company game to make money.  In the small print in the denial letters there was an option to appeal all denials to an administrative law judge within the state.  I asked my colleagues and nobody had tried that route.  I collected 12 denials and requested a hearing in front of the administrative law judge.  I took a day of vacation to go to court.  A week before the hearing I was informed that my hearing was cancelled and the administrative law judge decided in favor of the insurance company.  I appealed to the Attorney General on the basis of conflict of interest stating that the peer reviewers worked for a competing organization and therefore this was anticompetitive activity.  The AG informed me that they were independent contractors.  How can you be an independent contractor if you collect a paycheck from the organization that is denying care by your competitor?  It was clear to me that the state government was very friendly to the managed care industry.

The whole managed care strategy for rationing care or in  extreme cases shutting down entire psychiatric units was outlined in my previous post on overutilization.  It is the basic money making strategy of managed care organizations.  It essentially doubles down on rationing.  That occurs because hospitals are paid a set amount for taking care of people regardless of how long they are there and that amount is denied in as many as 10% of cases.  If there is one deficiency of this book it is a lack of granularity on this issue.  Dr. Torrey approaches the problem as a top down problem of policy deficiency, driven by an ideology that bed capacity could be shut down and not missed either because of the toxicity of state hospital settings or too much faith in the federal initiated community mental health movement. 

Assuming that a patient can actually get the level of acute care that they need without being thrown out of the hospital by an insurance company, the fragmentation of care does not stop there.  Even though insurance companies say they are emphasizing outpatient care, getting an appointment may be impossible.  The prescribed medications may be denied.  Housing options or community case management for people with severe mental illness are not usually available unless the insurance changes to a public option.

American Psychosis covers the funding and policy issues on a global level before it gets to the suggested solutions.  Excellent examples are given to illustrate these points.  For example, North Carolina is given as the example of what happens when a state mental health system is privatized (p 158).  The parameters of the dramatic deterioration in services that resulted from this maneuver is a well documented example of what happens when a for-profit entity begins to manage care and shift the responsibility for care of serious mental illnesses to the correctional system.

American Psychosis is a well organized analysis of the problems that occurred as the result of an initiative in the Kennedy administration.  It contains a lot of information and references about what has happened as the result of these decisions.  There is also a subtext and that is it is written from the perspective of a psychiatrist who has been a thought leader on the issue of treating people with severe mental illness.  Only a minority of people in the United States understand that perspective and I think that there will be predictable backlash from the constituencies that believe a severe mental illness is a preferred state and that everyone should have the right to enjoy it.  

That is not the experience of any acute care psychiatrist and Dr. Torrey presents that perspective very well. 

George Dawson, MD, DFAPA       

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