Friday, May 29, 2015

Minnesota Finally Rejects Managed Care

In a rather stunning reversal of thirty years of public policy, the Minnesota Legislature voted last week to fund for a "network of small treatment centers" to compensate for all of those years of rationing.  The details are still vague  but it is described in the StarTribune article by Serres as a "network of small treatment centers, to be built across the state, anchoring a broad package of preventive services so children don't end up in emergency rooms or inpatient psychiatric wards where many of them are discharged prematurely for a lack of beds."  The funding is about $13 million for 2 years and $6.6 million "to create a network of 30-bed treatment centers for children with highly aggressive or self-injurious behaviors, who are often turned away from hospital inpatient units."  Political speak is evident in that sentence.  I can't imagine that $6.6 million or even $19.6 million gets you a lot of 30-bed treatment centers.  Later in the article a total new bed capacity is described as 150.

The author of the article is oblivious to how this all happened in the first place.  Was Minnesota an idyllic place with no mental illness in the first place?  Did the problem arise because an epidemic of mental illness?  Absolutely not.  Thirty years ago, the state had more bed capacity and more treatment options for both children and adults with mental illness.  Minnesota is a state with massive managed care presence and those managed care companies currently run all of the acute care psychiatric beds in the state - for both children and adults.  Once managed care companies learned that they could deny hospitalizations based on some fictional "dangerousness" criterion and otherwise ration psychiatric services at multiple levels there was - in effect - no rational psychiatric care.  As I have posted on this blog many times, people are discharged from hospitals in a few days essentially without treatment, treatment units are chaotic without a therapeutic environment, people who require medical detoxification form drugs and alcohol are generally out of luck, and it creates and ongoing demand on emergency departments and correctional facilities.  All it took was getting these practices embedded in the state statutes and setting up a cursory review of complaints against managed care companies at the state level to seal the deal.  The reporter in this case makes it seem like the Minnesota Legislature and a "bipartisan coalition of lawmakers" are solving a problem.  This is a problem they created in the first place and I will believe in a solution when I see it.

I have some first hand knowledge of the problem with children's services from my contact with child psychiatrists around the state.  Their experiences are echoed in the story in this article of what happens when your child is out of control and nobody is willing to help.  The family in this case describes a 17 year old boy with severe mood problems, aggressive thoughts and thoughts of self harm.   He was hospitalized 6 times and discharged in a heavily medicated state.  He was turned down by 30 residential facilities before being accepted by an out of state facility.   His parents describe themselves in a "perpetual state of anxiety" trying to manage all of these scenarios.  But the most incredible line in the article:

"For years, children who exhibit highly aggressive or violent behavior in Minnesota have been forced to drift from one short term hospital to the next, often returning to their families heavily medicated but with their illnesses largely untreated."

This is not surprising to any psychiatrist.  This is the end product of managed care rationing and it occurs whether the patient is a child or an adult.  It happens when businesses and governments collude in providing some bastardized version of psychiatric care.  It happens when psychiatrists in this case are ignored.  When state officials ignore psychiatrists. When psychiatrists who are trained to treat aggressive and violent behaviors are not allowed to do their jobs.  After all, why would anyone with aggressive behavior because of a mental illness be turned away from a psychiatric unit?  Aggressive and suicidal behavior are the main reasons that psychiatrists exist today.  It is what we do.  Let us do our jobs.

So far this is one small victory for children's mental health advocates and my cap is tipped to them.  But to reverse more of the problem we need to acknowledge what it is and it is managed care or more specifically their marketing word for mental illness - behavioral health.

Let's get rid of it entirely.

George Dawson, MD, DFAPA


Chris Serres.  Facing chronic shortages, Minnesota's mental health system gets a boost.  Minneapolis Star Tribune, May 29.  

Supplementary 1:  The image used for this post is of Dexter Asylum attributed to Lawrence E. Tilley [Public domain], via Wikimedia Commons.  The original image was Photoshopped with a graphic pen filter.

Supplementary 2:  For a detailed post on some of what happened try this.

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