Saturday, June 28, 2014

We Are All Happily Making Money On Mental Health

I heard this story on MPR yesterday morning and could not wait to comment on it when I had the time.   One of the may ironies of this piece is that the entire managed care industry was invented and consolidated around the myth that mental health was out of control and needed outside "management".  That rhetoric continued to serve the purpose when the time came to drastically cut and restrict services on a disproportionate basis compared with all other aspects of medical care.  The original "offense" driving all of this pro-managed care rhetoric was a chain of psychiatric hospitals that were accused of inappropriately hospitalizing teenagers back in the 1980s.  The rhetoric was so intense and so perfect from a propaganda standpoint that any outcry against managed care in the past three decades was typically met by somebody bringing up what happened in the 1980s as proof that we need managed care.  Psychiatrists who should have known better kept mouthing these words as well as psychiatrists with conflicts of interest through their ties to the managed care industry.  Even as the psychiatric infrastructure was decimated, bed capacity was closed, access to psychiatrists was limited, and the severely ill could only be hospitalized if they were "dangerous" - we still needed managed care to prevent the alleged excesses of the 1980s.  As a psychiatrist who practiced in the 1980s in both hospital and community mental health center based practices - I can say that unequivocally there were no excesses in any hospital or clinic that I practiced or trained in.  That included three Veteran's Administration hospitals, a large county hospital, two community hospitals, and the community mental health center.  In fact by the end of the 1980's managed care reviewers were routinely throwing the patients that I was treating out of the hospital.  These were patients who generally had few resources severe mental illnesses and many had an addiction.  In many cases suicidal behavior brought them into the hospital and a reviewer who had never seen the patient decided that they needed to leave.

From a business standpoint, how can you not make money?  I can understand the excitement in the business community.  The PPACA is essentially another tax on all Americans.  It will generate a huge revenue stream.  The market is already concentrated in the hands of a few businesses.  The legislation itself facilitates the formation of even bigger cartels from the existing cartels.  The cartel controls all of the pricing, and of course they get paid whether or not the subscriber ever uses the system.  The cartel dictates what they pay the professionals in the system, and when they don't (in the case of rural physicians) - they try to get legislative leverage to force those physicians to accept what they pay everyone else.  They have institutionalized business practices to take priority over medical care.  They also have a well known tendency to treat knowledge workers like production workers, minimizing any activities that are not considered essential for the business. How can you not make money with a model like this?  Adding what is essentially unnecessary administration to medical services is the equivalent of adding the same unnecessary services to the financial services industry.  The consumer does not get a real choice of services.  There is an expectation that they will pay their money like everyone else, a surcharge for management practices that seem to add value based on public relations and advertising or in other words - no value at all.

Three decades of managed care has provided a clear example that making money is obviously not the same thing as providing quality care.  Funneling tax dollars and insurance premiums through a middleman whether that is a managed care company, insurance company, or pharmaceutical benefit manager has always been good for business.  It has been horrendous for physicians and not good at all for patients especially anyone with a mental health problem or problem with addiction.  There is nothing in the ACA that will change that.

The exuberance for investing in behavioral health is understandable.  Managed care has always been a money making scheme designed by business men and politicians to shift money away from the people and institutions providing care under the guise that some type of management was needed.  I don't buy for a second that this will translate into better access or less stigma.  Managed care companies don't have to produce a better product.  The should be evident by the metrics they have devised to measure things like the PHQ-9.

So rejoice if you are a healthy investor with no history of mental illness or addiction in your family.  Taking money from a captive audience and providing them with public relations based care is good for business.  It has a solid 30 year track record of providing some of the worst mental health and addiction care ever while many of the companies involved prospered and were seen as excellent investments.

How does providing these companies and managers with unprecedented leverage over the system change any of that?  There will be the expected proliferation of managers, all of who have the express agenda of rationing the amount of care you can get for your premium.  There will be the marketing campaign so that it appears that every hospital and clinic in your community will be one of the top institutions in the country.   In the end, you  will still not be able to get detox and addiction services, hospital care or psychotherapy much beyond the severely rationed services that exist right now.  The mainstay of psychiatric services will still be a 10-20 minute conversation focused on a medication with a psychiatrist or more probably a less expensive "prescriber".  There will probably not be much of a conversation on whether that medication makes sense and what the other alternatives may be. Anyone being seen in some versions of the collaborative care model may not ever see a mental health professional.

But somebody will be making money and a lot of it.

George Dawson, MD, DFAPA

Dan Gorenstein.  Mental health parity opens  new business opportunities.  MPR Friday June 27, 2014.

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