Wednesday, November 2, 2016

Another Bad Editorial Decision and more.....

I am on record recently pointing out how top medical journals have evolved to the point that they are posting a continuous stream of opinion pieces of variable quality.  It is not uncommon to find that from week to week diametrically opposed views on topics are published.  The most alarming trend in the posting of business views; usually along the lines that there needs to be continuous business reform in health care.  These are basically opinion pieces looking for a political foothold.  The precedent of course is managed care.  After it gained a political foot hold in the Clinton administration it became a business worth hundreds of billions of dollars.

In the case of managed care it was sold as widespread "reform".  After 30 years of managed care rationing the per capita health care costs in the USA are quite unbelievable when compared with even the next most expensive system ($9,086 in USA versus $6,325 in Switzerland).  The other top ten nations are seriously outdistanced.  Rather than acknowledge managed care as just another political flop there are endless editorials on how it really slows the growth of health care.  There are editorials of how it is really a success despite these outrageous numbers and nearly complete hegemony by managed care and insurance companies.  It is difficult to see how responsible editors of medical journals can continue to publish this pro-business propaganda.  They are certainly more circumspect about making these pages a sounding board for the pharmaceutical industry.

The largest divergence when it comes to health care costs is a managed care propensity for a disproportionate focus on mental health and psychiatric services.  This is nothing new.  It has been well documented since the  Hay Group found that from 1988 to 1997 that a total value of health care benefits for over 1,000 large U.S. employers declined by 10%.  Of the decline general health care benefits declined by 7%, but behavioral health benefits declined by 54%.  Behavioral health is managed care speak for mental health and psychiatric services.  Those same services dropped from 6% to 3% as a total percentage of health care costs.  While general medical services increased by 27% outpatient mental health services dropped by 25%.  Mental health benefits from employer based health insurance dropped by 50% between 1988 and 1998.  The true costs of managed care rationing have never been seriously examined.  There is an obvious conflict of interest when the government basically invents and industry based on a flawed political theory and the system floats based on these invented special interests.  

I did not really think that these opinion pages could be any worse until I happened to open up JAMA Psychiatry the other to do some reading while I ate my Wheaties.  I ran across an article called "What to do when your managed care firm says no."

The answer from my experience is nothing - you are basically out of luck.  In my experience managed care companies don't care if you live or die.  They don't care if you have the world's worst eating disorder.  They don't care if you have tried to kill yourself while intoxicated and your psychiatrist is saying that you will absolutely use alcohol, heroin, methamphetamine, dextromethorphan or any number of drugs immediately if you are not sent to treatment after acute stabilization.  They don't care if you need a longer period of time in the hospital.  They don't care if you have been committed for a suicide or homicide attempt.  I am not saying all of this just because it is true.  I am saying it to point out something that is often overlooked.  Why would a managed care company or MCO care?  They have never met you and have no personal responsibility to you.  As a business, especially in the new era of business management - they basically have a responsibility to make money for their shareholders.  The caring aspect of MCOs is really a public relations stunt.  They involve your doctor and make it seem like their decision - is your doctor's decision.   They waste your doctors time in order to make it seem like their refusal to pay for your care is somehow a conjoint decision with your doctor.

But back to the article.  Here we have a managed care insider giving advice to patients and physicians on how to deal with their denials.  I would consider this all tongue in cheek advice if it was not sitting right there in JAMA Psychiatry.  I will focus on a most familiar scenario denial of inpatient care.  This is a case of a hospitalization for schizophrenia where "the hospital tells the mother that it is time to discharge her son because the MBHO (Managed Behavioral Health Organization) says so and has an appointment for her son to be seen a month after discharge" (p. 1109).  The author suggests that in the case of this dispute the vendor will have a formal appeals process and that will include "a review by a psychiatrist not on the MBHO's payroll."  That has not been my experience.  The review is generally done by psychiatrists a long distance away.  They may not be licensed in the state where the patient is hospitalized.  The ones I have talked with are either openly hostile, pretending to be on your side, or clueless about the severity of inpatient problems.  Keep in mind that most psychiatrists do not practice in inpatient settings beyond their training years.  I have never seen a study that looked at whether these reviewers were actually treating very ill psychiatric inpatients - but from my conversations I think they were not.

The author goes on to say that the family can then apply to the employers benefits manager to apply leverage to the MBHO and have leverage in the case of inadequate care.  What is wrong with that picture?  For starters any sequence of events where clinical decisions are being made by business types is by definition - inadequate care.  Secondly, there is an inherent conflict of interest when your employer and an insurance company they are contracting with start negotiating your medical or psychiatric care.  Once again - neither of them has a responsibility to you for giving you the best possible medical advice.  They are giving you a business decision that saves them both money and calling it a medical decision.  The MBHO is protected against liability from that decision by federal law.  Your employer is protected by saying it was the decision of the MBHO and not them.  If you really think that your employer is interested in your personal health, go talk to the decision maker in person and note their level of interest.

The final vignette provided by the author is there to justify managed care.  It has been their war cry since day one and that is excessive utilization.  In this case we are lucky to have Big Brother watching in the case of psychotherapy delivered so inexpertly that the therapist states: "I am this patient's only friend so she needs to to keep seeing me."  This was after years of treatment.  I think that we can  all breathe a sigh of relief that an MBHO being paid millions plus incentives to ration psychiatric care can identify the worst therapist in the USA after years of therapy.  It is a miracle of modern management.

When you have editors who accept this level of an article it is a direct insult to anyone who has personally dealt with these companies and who knows what is going on.  It is a direct insult to the medical profession and physicians who have dedicated their lives to learning complex, highly technical profession to suggest that they should be clerical workers and work for free as employees of managed care companies.  It is an insult to desperate patients and their families who put up with all of paperwork, inefficient billing and arbitrary denials of care.

If the editors of medical journals are not bright enough to question the accuracy of a piece like this or they have not had the clinical experience of dealing with the constant harassment of managed care companies - they should defer the commentary section to somebody who knows what they are talking about.

Better yet - time for a moratorium on business and political commentary in medical journals.  When you try to complete with blogs - keep in mind that you are competing with a low standard.  That turns out to be no competition at all.  

George Dawson, MD, DFAPA


1: Essock SM. What to Do When the Managed Care Firm Says No.  JAMA Psychiatry. 2016 Sep 28. doi: 10.1001/jamapsychiatry.2016.2409. [Epub ahead of print] PubMed PMID: 27680607.

Supplemental -  The 4 x 6 Card on Real Health Care Reform

No room for this in the original above.  The solutions to businesses and business managers making medical decisions about your health care is like most political quagmires in this country - very simple.  You can fit it on a 4 x 6 inch index card.

It goes like this:

1:   All managed care (MCO, MBHO) decisions are between the patient and the company.  The doctor is out of the loop.  The doctor advises the patient, the company says yes or no on the payment.  The doctor may have an alternative or the doctor may not.

2:  The doctor does no appeals , paperwork, reviews with the MCO.  Why would he/her?  The doctor does not work for the MCO and does not get paid for all of the time it takes to engage in what are business processes.  The doctor should not care what anything costs the MCO.  They have a tower of MBAs with nothing else to do but figure that out.

3:  The same process is true for PBMs (pharmacy benefit manager) - the pharmacy equivalent of MCOs.  The doctor does not work for the PBM and does not get paid for all of the extra time each day to essentially justify their decisions.  PBMs have another tower of MBAs with nothing else to do but price drugs to their advantage. 

4:  The MCO is liable for damages related to any of their financing decisions that result in harm to the patient.  No federal exceptions.

5:  Each state has an independent arbitration board comprised of physicians who are actively practicing in the discipline where the decision is being appealed.  The physicians are all actively screened for conflict of interest like the Medicare Peer Review Organizations that found there was no excessive use of mental health services or anything else in about 1998.  The arbitration board should contain only physicians - no insurance company insiders dedicated to shield the managed care industry.  Direct appeals by the public should be encouraged with the same amount of vigor that the public is actively solicited to complain against their physicians.   

Steps 1-5 above would assure physician recommendations in the best interest of you the patient rather than the financial interest of the managed care organization.  Unfortunately with Managed Care 3.0,  the rationing in many cases has been internalized.  Today physicians can be in a clinic or hospital setting that has internal case managers telling them what to do.  When managed care companies rationed some places out of business they were very successful in acquiring medical groups and facilities.  In other words; the doctors, the hospitals, the clinics and the pharmacies are all owned and run by the managed care company or a shell company.  They all get their marching orders from people in the management class pretending to be medical experts.

That should be a major problem - but in the manner of Orwell - if you use the term health care reform a thousand times - most people believe it happened.

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