Tuesday, October 22, 2013

APA Continues to Hype Managed Care

This YouTube video is fresh off my Facebook feed this morning from the APA.  It features American Psychiatric Association (APA) President Jeffrey Lieberman, MD discussing the advantages of a so-called collaborative care model that brings psychiatrists into primary care clinics.  I have critiqued this approach in the past and will continue to do so because it is basically managed care taken to its logical conclusion.  As opposed to Dr. Lieberman's conclusion, the logical conclusion here is to simply take psychiatrists out of the picture all together.

A prototypical example of what I am talking about is the Diamond Project in Minnesota.  It is an initiative by a consortium of managed care companies to use on of these models to monitor and treat depression in primary care clinics in the state of Minnesota.  In this model, patients are screened and monitored using the PHQ-9 a rating scale for depressive symptoms.  Their progress is monitored by a care manager and if there is insufficient progress as evidence by those rating scales, a psychiatrist is consulted about medication doses and other potential interventions.  The model is described in this Wall Street Journal article.  As is very typical of articles praising this approach it talks about the "shortage" of psychiatrists and how it will require adjustments.  In the article for example, the author points out that there would no longer be "one-to-one"  relationships.  There are two major problems with this approach that seem to never be not considered.

The first is the standard of care.  There are numerous definitions but the one most physicians would accept is care within a certain community that is the agreed upon standard provided by the same physician peers.  In this case care provided by all psychiatrists for a specific condition like depression.  There are professional guidelines for the care of depression and in the case of primary care guidelines for care provided by both family physicians and internal medicine specialists.  One of the tenants of this care is that physicians generally base treatment of an assessment that they have done and documented.  The only exception to that is an acceptable surrogate like a colleague in the same group covering a physician's patients when they are not available.  That colleague generally has access to the documented assessment and plan to base decisions on.  This is the central feature of all treatment provided by physicians and is also the basis for continuity of care.  As such it also forms the basis of disciplinary action by state medical boards and malpractice claims for misdiagnosis and maltreatment.  An example of disciplinary action based on this standard of care is inappropriate prescribing with no documented assessment or plan - a fairly common practice in the 1980s.

In all of my professional life, the standard of care has been my first and foremost consideration.  It is basically a statement of accountability to a specific patient and that is what physicians are trained to be.  Curiously it is not explicit in ethics literature and difficult to find in many state statutes regulating medical practice.  That may be due to the entry of managed care and the introduction of business ethics rather than medical ethics.  It also may be due in part to an old community mental health center practice of hiring psychiatrists essentially to refill prescriptions rather than assess patients.  This is addressed from a malpractice perspective by Gutheil and Appelbaum in their discussion of malpractice considerations and how they changed with the advent of managed care:

"Managed care is one omnipresent constraint.  Patients and clinicians must work together to fashion an appropriate treatment plan to take into account available resources and given the contingencies faced by the patient.  If that plan-properly implemented-fails to prevent harm to the patient, the clinician should not face liability as a result." (p 164).

They go on to explain how ERISA - the Employee Retirement Income Security Act of 1974 indemnifies managed care companies and their reviewers from the same liability that individual physicians have.  They cannot be sued for negligence and the resulting harm.  So managed care can take risks without concern about penalties as opposed to physicians who are obliged to discuss risks with the patient.  Managed care organizations can also implement broad programs like depression screening and treatment without a physician assessment and consider that their standard of care.

The second problem with the so-called collaborative care approach is that there is no evidence that it is effective on a large scale.  I pointed out this criticism by a group of co-authors including one of the most frequently cited epidemiologists in the medical literature.  That group has the common concern that a rating scale is a substitute for an actual diagnosis and everything that involves and given the recent FDA warning on citalopram.

Both of these concerns bring up an old word that nobody uses anymore - quality.  It is customary today to use a blizzard of  euphemisms instead.  Words like "behavioral health", "managed care", accountable care organizations", "evidence-based", "cost-effective" and now "collaborative care".  According to Orwell, the success of such political jargon and euphemism requires

"an uncritical or even unthinking audience.  A 'reduced state of consciousness' as he put it, was 'favorable to political conformity'." (3 p. 124)

Dr. Lieberman uses a lot of that language in his video.  The critics of psychiatry in the business community do the same.  There appears to be a widespread uncritical acceptance of these euphemisms by politicians, businesses and even professional organizations.

An actual individualized psychiatric diagnosis and quality psychiatric care gets lost in that translation.

George Dawson, MD, DFAPA

1.  Beck M.  Getting mental health care at the doctor's office.  Wall Street Journal September 24, 2013.

2.  Gutheil TG, Appelbaum PS.  Clinical Handbook Of Psychiatry And The Law. 3rd edition. Philadelphia: Lippincott Williams & Wilkens.  2000, p 164.

3.  Nunberg G.  Going Nucular: language, politics, and culture in confrontational times.  Cambridge: Perseus Books Group, MA 2004.

4.  American Psychiatric Association Principles of Medical Ethics with Annotations Espcially Applicable to Psychiatry.  2009 version.


  1. The PHQ-9 is completely invalid for making a diagnosis of major depression (versus dysthymia or having an adjustment disorder or just dysphoria secondary to interpersonal problems). I quoted your June 17th post on this subject on a post on my own blog in discussing the reasons that this is true, http://davidmallenmd.blogspot.com/2013/10/counting-symptoms-that-dont-count-part.html.

    I wonder if there is any way like-minded people can get together with us to better sound the alarm about this travesty of psychiatric "care." Blogs are easy to ignore.

    1. I agree with you about blogs being easy to ignore. Conan Obrien joined Linked In yesterday and commented that by blogging he would join the billion brightest people on the planet. That is an ironic characterization of the blogosphere.

      The problem as far as I can tell is that physicians as a group are too complacent and much less likely to make waves than others. They seem quite content to put up with the tremendous amount of grief put upon them by the government and business worlds. There are factions within medicine that criticize any physician who stands against these forces. I just spoke with an internist today who talked about how he and other internists deplore the current hospitalist model of care and how numerous articles in the literature over the past 15 years have documented its clear deficiencies, but it is widely deployed by the managed care industry. He described the same problem I posted here about psychiatry - partial hospital evaluations and no follow ups. He also pointed out that these same health care organizations could make it easier for their internists to follow their hospitalized patients by providing nocturnists who would take call on their patients at night and reduce some of the burnout - but they don't.

      Over the past two decades I have seen a lot of suggestions on how to organize come an go - from unionization to Sermo. None of it is effective in a political system where physicians and their lobbyists can routinely be ignored and Congress can invent and fund medical businesses by a health tax levied on everybody.

      My current best idea is to organize like minded bloggers and get the message out. Posting on each others blogs will increase visibility in search engines and get the word out on the Internet instead of the usual media stories (like the one above) that generally favor managed care. The people writing these stories don't have a clue about how the health care system works and their usual default position is to try to scandalize psychiatry

  2. This was an excellent article.

    In response to Dr. Allen's question, the answer is for turkeys to stop paying dues to the American Thanksgiving Association.

    1. If that would make the APA change it's policies or even go away, I'd agree. But since they are probably here to stay, we need people on the inside to at least try to keep its negative tendencies in check.

  3. Dr. Allen, I wish that were a possibility, but the APA is dominated by academics on salary who love theory over reality and don't understand or are indifferent (or even hostile) to the economics of private practice. Paying dues to APA and AMA is selling them the rope to hang us with. 85% of doctors realize this about AMA but for some reason, many private practice psychiatrists have trouble dumping APA even though they should be horrified by Lieberman's comments.

    And BTW, if you enjoy APA CME activities, you can still attend at a higher cost. Frankly, I think they are pretty basic and you can do better if you shop around.

    Lieberman is doing more damage to psychiatry than Scientology can dream of doing.

    1. Maybe so, but what's the alternative? A small chance of having an impact is still better than no chance at all.

  4. You have more chance of getting them to pay attention by hurting them in the pocketbook than changing their minds through dialogue. All APA Presidents in recent years are cut from the same cloth.

    I don't see why APA has to be a monopoly. Psychologists who were sick of their APA formed the Association for Psychological Science which is a superior organization.

    1. Well, we did have Harold Eist a few years ago. Granted, no one like him since.

      I just don't think there's enough of us to hurt the APA in the pocketbook, frankly.

      I wish we had an effective alternative to the APA, but right now there isn't one. As to the psychologists, CBT'ers who grossly exaggerate their evidence base, ignore human relationships, and deny funding to other types of psychotherapy outcome studies still dominate clinical psychology, so I don't know how much good that other organization is really doing.

      I'm certainly open to anyone with new ideas about how to better get the word out.

      At least at the APA annual meeting, opposing voices do have a forum. Mark Zimmerman presented on the evils of symptom checklists and about patients with borderline personality disorder being misdiagnosed as Bipolar. My colleague from Australia, Peter Parry, presents the other side on pediatric bipolar disorder. I presented on the neglect of social psychology by the field. And folks like us get up and challenge nonsense with questions after stupid presentations.

      We need more people like us at the meetings, not fewer.

  5. I find the video clip infuriating. As for what to do, it seems to me that psychiatrists aren't the only interested parties when it comes to problems with collaborative care. What about the primary care docs? Don't they already have enough on their plates? And won't they have even more once everyone has insurance coverage? And don't get me started on the checklists.
    I had the thought that Change.org might be an option. Unlike Sermo, it's not restricted to physicians. But the whole thing feels kind of hopeless to me.
    As for the APA, they're already hurting financially. They have diminishing funding from Big Pharma, which may be why Lieberman wrote recently about making nice to pharmaceutical companies (See:http://psychpracticemd.blogspot.com/2013/08/who-needs-who.html). They have fewer dues-paying members than they used to, and fewer attendees at meetings. And I'm betting DSM-5 isn't bringing in the revenue they expected. So I don't know. Maybe encouraging psychiatrists to tighten their pursestrings might have some impact.

    1. The politics of this is always interesting. About 20 years ago, I can recall having a conversation with several other specialists in our hospital cafeteria. It was very collegial. I had known some of them since we were all interns on Internal Medicine. Somebody had picked up the fear that 'Things were going to change." Our entire group was intimidated by that rhetoric and we ended up making sweeping changes that eventually shifted the power from physicians to a managed care company.

      The rhetoric of change: "Change is good, replace the authoritarian doctors, etc..." is a common MCO tactic. It is amazing how easily physicians folded and started to march in lock step with the next bad idea. As we now know there is an unending stream of bad ideas.

      I also find it very interesting that the real conflict of interest here is with managed care companies and not pharmaceutical companies. The idea that Big Pharma is making psychiatrists rich has always been an absurd idea but it is even more laughable now with abundant generics. Big Pharma has the advantage that they can bundle all of their profits into a nicely packaged product that they don't have to negotiate much over. Physician services on the other hand can be almost totally devalued and the physicians affected the most - employees of MCOs almost never speak out about what they are seeing and end up going along with all of the bad ideas.

      If I had to guess what would make the most difference, I would say a whistleblower clause indemnifying MCO physicians would potentially be the most helpful. But I can't see how that would pass a Congress that still blindly sees these companies as cost saving surrogates and is in the process of greatly expanding that experiment.

      The APA may be thinking it is easier to join them then fight them - especially when there were very few people fighting them in the last. I think their concessions on MOC and soon MOL to ABMS is an extension of this process and exactly the opposite of what most members.

    2. To be fair, I don't think the charge of big pharma influence is laughable, but it is overblown. You brought up Schatzberg in another post, if you look at his case a couple of years ago, it really did look bad for the profession. However, you don't want the situation you have now, where pharma is running for cover and not developing new drugs.

      The APA is playing a dangerous game here, offending many of its members by supporting policies that harm them. There is a huge gulf ideologically between the academic leaders at the top and the grass roots.

      It wouldn't be the first time a speciality was led astray by "thought leaders". Pain management is still recovering from the what me worry about opioids campaigns of the 90s. Maybe we should be a little more careful about the influence we give these organizations to determine practice standards.

    3. Certainly agree with overblown. I think the APA also prematurely caved in this situation. The obvious question is why psychiatrists were singled out when it it well known that many college professors make significant sums of money consulting for industries. In some cases, their professional organizations make a point to invite all of the major businesses that may be affected by their standards to the meetings. The end result here is that we now have the industry split from the professional group most interested in its product.

      A firmer stance with Grassley may have produced some of these answers. Instead we will never know and there will always be some impact on the image of psychiatry.

      Two related issues include the issue of overprescribing in general. The CDC program to reduce overprescribing of antibiotics has been declared a failure by some after 25 years. A CDC rep recently came out and proclaimed we have entered the "post antibiotic era" based on people in hospitals with infections who cannot be treated. No apparent fallout to any physician group for this overprescribing and no connection with "industry influence" despite similar dynamics between physicians and Big Pharma.

      You make a good point about the opioids. The Joint Commission was also involved in promoting more aggressive pain management in 2000. Opioid overprescribing in chronic noncancer pain is clearly a massive problem based on poor data and politics.

  6. While others may worry about global warming and terrorism, I am far more concerned about the increase in MRSA, because this could be the new AIDS except that everyone is in the risk group. And I am not by nature an alarmist.

    The public can't blame that one on pharma but themselves, specifically fretful mothers who have just enough knowledge to be dangerous. If the pediatrician doesn't buckle when mom insists on a Z-Pac, because, well, she just knows, be prepared for that negative performance evaluation. It's a wonder all pediatricians aren't our number one patient demographic with what they have to deal with.

    Because of this, I know two formerly healthy people with chronic vanco resistant MRSA, and I recently went to a funeral for a marathon running cop who was dead in three days from IV antibiotic resistant meningitis.

    Psychiatrists have an overprescription problem, but nothing as serious as in pain management/ortho (300 dead per week from ODs) and pediatrics.

    We need to address antibiotic resistance with the fast track methods that led to HIV triple therapy NOW. And if that makes some big pharma CEO a billionaire, good for him.

    1. You put your finger on a very important point. If patients demand drugs and instead the doctor tell them they need therapy instead of (or even in addition to) medication, the patient put up negative reviews on doctors' ratings sites.

      Then there's the issue the "quality" checks in Medicare which encourage doctors to only treat uncomplicated patients and refuse the difficult ones with poorer prognoses. It's a bit like rating teachers in poverty areas in exactly the same way you rate them in affluent areas, as if they were the only factor operating. Psychiatrists in particular are like a bunch of lemmings (as we used to understand them before that Disney nature film that showed them diving off a cliff was found out to be a fraud).

  7. Lest anyone read this and think we are being tough on Lieberman and the APA, check this response out from a doctor in SciAm:


    I can't say I disagree with anything she says.

    So if someone in private practice was head of the APA, and repeatedly advocated that academic heads of departments take a 40% pay cut and be required to see 40 patients a week, how do you think someone like Lieberman would react? Yes, it would get personal. That's essentially what he is doing to most of his base. This is what happens when an ivory tower type on salary who is involved in research and not patient care tries to make himself out to be an expert on health care systems delivery.

    1. That blog is a mess. It shows how far afield people can get when they get riled up about psychiatry. The response thread is interesting when Justin Marley gets involved and tried to point out the inherent conflicts of interest.

      The only hope for psychiatry is to stay on point and quite literally ignore the people who don't know what we are doing. Your point is well taken but I am also concerned about academics who are now confronted by some administrator and told that they have to earn their keep by generating RVUs. To me that defeats the purpose of an academic department and is an application of a managed care strategy to managed what is typically a public institution. The question is are there administrators anywhere who know better than this these days? I have not seen any and it will lead to the destruction of academic psychiatry.

    2. Just to clarify, I'm not advocating that model for academic psychiatry, I agree it would be a disaster. I'm a live and let live guy. The point was that just like private practitioners shouldn't be telling academics how to structure their departments, academics shouldn't be advocating square peg-square hole models for private practice. It's arrogant and reflects the conceit of central planners. As behavioral experts, we should realize that central planning doesn't work.

      Lieberman is both condescendingly arrogant and oblivious to private practice realities, and that makes him very dangerous. I'm sure at one point in his career he would have been horrified if a resident prescribed without doing a mental status exam. I don't know how you can just toss those basics aside. Fabians have a way of making science subordinate to theory.