Showing posts with label Mental Health Parity and Addiction Act. Show all posts
Showing posts with label Mental Health Parity and Addiction Act. Show all posts

Sunday, September 13, 2015

Is Mental Health Legislation Really The Joke That I Think It Is?




The above graphic is a headline search of mental health parity going back to 2004.  I was in the thick of things from 2009-2012 as the transitioning President of a District Branch of the American Psychiatric Association - the Minnesota Psychiatric Society.  Not that it gave me the inside track on anything.  I think officers in district branches spend most of their time trying to get members motivated to do something.  My strategy was basically to approach things in the way I do on this blog.  I don't think that is was any more or less successful than the dialogue promoters, but at one point some people became uncomfortable when I suggested that one of the hospitals could have been managed better.  It was apparent to me at that time that professional organizations do not tolerate disagreement very well.  As far as I can tell, there can be no real changes in organizations without disagreement and disagreement should be expected anytime there are people who want to talk endlessly and people who want action.  On the other hand nobody has to take it personally.  That may not be possible in Minnesota or in professional organizations.  I have previously referred to it here as the "big tent" approach where multiple goals are tolerated even some that conflict with the overall goals and ethics  of the organization.  An example would be prior authorization of medications.  The vast majority of members find it extremely intrusive and a waste of their time, but the members who are executives in managed care organizations do not.  Accepting both of those positions is a tacit acceptance of prior authorization while working with the members to change it.  How do you think that will work out?

Parity or equal coverage for mental illness and physical illness was a legislative initiative of two U.S. Senators Paul Wellstone and Peter Domenici.  Both had personal experience with the problem having family members with severe mental illness.    That personal experience remains critical in the political and cultural landscape.  There are still plenty of people pushing the "myth of mental illness" fallacies.  Some have moved on to just blame psychiatrists.  People with experience recognize those arguments for what they really are and can try to proceed with real solutions.  I never met Paul Wellstone, but I liked him a lot.  He was one of a handful of US Senators who voted against authorizing the invasion of Iraq based on the flawed weapons of mass destruction argument.  He was vilified by some for the vote and referred to as an ultra-liberal.  That is a glib characterization during an era where there are no liberals.  In Minnesota he was widely known as a populist.  People perceived him as a common man who cared about the common people.  He was tragically killed in a in a plane crash in northern Minnesota in 2002 while campaigning for his fourth term in the Senate.  Senator Domenici retired from the Senate in 2009, after the longest tenure at that position by anyone from the state of New Mexico.  My guess is that the final form of this bill and the way it is implemented was not the intent of either of these Senators.

I read through several iterations of their bill until it became The Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA).  All of those versions are available on the Congressional web sites, but the factsheet is available from CMS.  It should be fairly obvious by any casual read of the factsheet that there are so many exceptions and vagaries associated with this law that it would not take the insurance industry and their government affiliates long to shred it.  I pointed this out at the APA 2011 Annual Meeting in Hawaii.  There was a meeting about how the MHPAEA was going to revolutionize the care of people with addictions.  A prominent psychiatrist and government official was scheduled to be there to explain how this was going to happen.  At the time, the impact of the law was not apparent on any of the acute care services where I was working.  At the meeting after listening to an overenthusiastic presenter explain how funding all of these programs were going to greatly increase bed capacity and services for all, I asked the simple question: "What would prevent any managed care company from providing a screening test and calling that assessment and treatment?"  The answer was "Nothing would prevent that."  No elaboration.  No discussion of how employers can just opt out of mental health and substance use treatment.

That introduction allows me to flash forward to the current time.  I was recently interested in referral for an acute psychiatric hospitalization in the Twin Cities - a metropolitan area of 3.8 million people.  According to a 2007 state report there were a total of 563 acute care beds for that area or 14.8 beds per 100,000 population.  According to the Organisation for Economic Co-operation and Development (OECD), the US ranks about 30th of 35 ranked industrial countries in terms of psychiatric beds per 100,000 population and the Minnesota metro is significantly below the US average of 25/100,000.   Based on those factors it should not be surprising that I was advised that there were no available beds and that the emergency department we could refer to had a 30 hour wait for assessments.

Compare that to Cardiology services in the same area.  Any middle-aged person (or younger) with chest pain would be immediately admitted to a coronary care unit or telemetry and have a standard evaluation completed even if they were discharged or undergo emergency catheterization and angioplasty/stenting.   I have never heard of a wait for acute Cardiology services.  I have never heard of a 30 hour wait in the emergency department for Cardiology services.   My point here is that the MHPAEA or parity legislation has done exactly nothing for the availability of acute psychiatric services.  These same numbers and waiting times in the ED have been there for the past 15 years.  There is no parity as long as there is no equal funding, and mental health services are funded at a fraction of what Cardiology services are.  Walk through any modern Cardiology Department or Heart Hospital and ask yourself: "Where are the equivalent psychiatric or mental health services?"  There are a few exceptions but generally not many and even then, a new facility is still managed by rationing strategies that result in people being discharged with inadequate plans and before their problems are completely addressed.  Inpatient psychiatric services are in effect behind a firewall and accessible only through the bottleneck in the ED.

The grim picture of acute care mental health services is only exceeded by the state of acute care addiction services.  As early as 1988, I was being advised by managed care companies that I could not detoxify patients with alcohol dependence on inpatient psychiatric units,  even if they had significant psychiatric comorbidity like suicidal ideation and depression.  The picture has gotten progressively worse since then.  It is common practice these days to send alcohol dependent people home with benzodiazepines and expect them to manage their own detox.  The lack of functional detoxification services keeps many people in the cycle of addiction to benzodiazepines, opioids and alcohol.

Confirmation of my skepticism about parity came in the form of the Mental Health Reform Act of 2015.  It is also a bipartisan bill introduced by Senators Bill Cassidy (R-Louisiana) and Chris Murphy (D-Connecticut).   There are House and Senate versions.  Both establish a new assistant secretary position for mental health and substance use disorders under the Department of Health and Human Services (HHS).   The fate of the Substance Abuse and Mental Health Services Administration (SAMHSA) hangs in the balance and getting rid of this highly flawed agency should be a priority.  SAMHSA has been the lead agency for mental health during this time of no parity and has not said anything about it.  The remaining description of the bill has to do with education people about HIPAA (do we really need that?) and insurance company accountability for a lack of parity.  The fanfare for this bill including praise from the APA is the exact same way the parity legislation started.  It should be evidence to every American by now that Congress is really interested in appearing to do something and appearing to want reform rather than getting the job done.

I don't think that there is anyone in Washington who knows the meaning of the word reform.  Until politicians everywhere realize that mental health services and substance use services have been an easy way for health care companies to make money by denying reasonable services nothing will happen.   It would help legislators to realize that they also have the highly flawed idea that managed care actually saves money and it is a conflict of interest for them to continue to promote this middle man on that basis.  I am not holding my breath, but it should be obvious that when a reform bill happens every 7 years, and there are still 30 hour emergency department waits and no acute care beds for admissions - there is no parity and there has been no reform.

George Dawson, MD, DFAPA





         

Sunday, April 14, 2013

Bipartisan Agreement on Treating Mental Illness - Believe It when You See It

The New York Times has an incredibly naive article on how legislators may be split on gun control but both parties support better care for people with mental illnesses. The article alludes to a bipartisan plan that would "prevent killers .....from slipping through the cracks."  The next paragraph says that the plan: "would lead to some of the most significant advancements in years in treating mental illness and address a problem that people on both sides of the issue agree is a root cause of gun rampages."

That would be groundbreaking news if it were true, but let's be realistic.  The history of funding treatment for addictions and mental illnesses in this country has been a downhill spiral for at least 30 years and there are no real signs that will changed.    Congress has essentially been at the root of the problem.  Congress after all is responsible for the disproportionately poor level of funding for the treatment of mental illness.  Congress basically invented the managed care and pharmacy benefit manager industry that has increased the rationing of psychiatric services that has led to the current deterioration.  Rather than focus of providing quality in the services that federal, state, and local governments typically provide (like community mental health centers, case management, civil commitment, protective services, and crisis intervention) they have adopted the managed care model of rationing services.

The only relative bright spot in mental health legislation was a parity law spearheaded by Senators Wellstone and Domenici.  The actual boilerplate is one thing and there was always a question about managed care would react to the parity law and if they could continue their successful rationing techniques.  Events in the past week suggest that they are as evidenced by the New York State Psychiatric Association and the Connecticut Psychiatric Society joining in a class action lawsuit against United Health Care and Anthem Health Plans for violations of the Mental Health Parity and Addiction Equity Act (MHPAEA).  The interesting aspect of the alleged "violations" is that they are standard rationing tactics that have been used by this industry for decades.

There are surprisingly few details of "improved mental health care" provided in this article.  There are many legislative tricks to make it seem like something has happened when it really has not.  The mental health issue seems like a safe haven for legislators who don't really want to address the gun issue.  I have posted some of the rhetoric on the issue here and some of it is fairly grim.  The President's initiative in the article involves over $100 million for screening.  There is no good evidence that screening adds much more than getting people on medications as fast as possible - probably too many people.

A related issue with Congressional lawmaking is that they rarely seem to consult anyone with expertise.  Many consider themselves to be experts in something even though they have never trained or worked in the field.  The people with the most significant access are business lobbyists and in many cases they are writing the laws or at least very satisfied with what is happening.  The focus is generally on improving the wealth of the folks with the lobbyists.  That is unfortunate because there are numerous ways to improve the provision of psychiatric services for severe mental illness without giving away more money to managed care companies.  The idea that "the most significant advancements in years in treating mental illness" will come out of Congress and business lobbyists sets my teeth on edge.


George Dawson, MD, DFAPA

Jeremy W. Peters.  In Gun Debate No Rift On Care for the Mentally Ill.  New York Times April 12, 2013.

Thursday, September 13, 2012

Why Are There No Detox Units Anymore?


Acute withdrawal from drugs and alcohol can kill you in the worst case scenario and at best can prevent you from initiating the recovery process.  So why are there no detox units anymore or at least very few of them?  You can still end up in a hospital going through detoxification or in a county facility where the priority is more containment of the acutely intoxicated than appropriate medical detoxification.  There are probably a handful of detoxification facilities where you will see physicians with an interest or a specialty in addiction medicine using the best possible standards. Why is the government and why are the managed care systems that run healthcare in the United States not interested in "evidence-based" medical detoxification?

As a person who has seen the system devolve and who has successfully treated a lot of people who needed detoxification this is another deficiency in the system of medical care that is never addressed. Over the course of my career I have seen patients admitted to internal medicine services for detox in the 1980s. When insurance companies and managed care companies started to refuse payment for that level of treatment intensity patients requiring detoxification were then admitted to mental health units.  When mental health units started operating according to the managed care paradigm of no treatment for people with severe addictions, they were either sent home from the emergency department or sent to county detox facilities.  Those county detox facilities were often low in quality and one incident away from being shut down.

I currently teach physicians about the management of opioids and chronic pain in outpatient settings.  I am impressed with the number of addicted patients who are taking opioids for chronic pain.  This population frequently has problems with benzodiazepines.  There is a general awareness that we are in the midst of an opioid epidemic and in many counties across the United States the death rate from accidental drug overdoses exceeds the death rate from traffic fatalities. The question I get in my lecture is frequently how to deal with the addicted pain patient who is clearly not getting any pain relief from chronic opioid therapy and has often escalated the dosage to potentially life-threatening amounts.  In many chronic pain treatment algorithms this is the "discontinue opioids" branch point.   During my most recent lecture I posed the question to these physicians: “Do you have access to a functional detoxification facility?"  Not surprisingly  - nobody did.

I can still recall the denial letters from managed care companies when I was taking care of patients with alcoholism and addiction in an inpatient setting. They had been admitted to my inpatient mental health unit and many were also suicidal. The typical managed care comment was "this patient should be detoxified in a detox unit and not admitted to a mental health unit.”  This is an example of the brilliant concept called "medical necessity" as defined by a managed care company. In the majority of these cases, the patient's county of residence did not have a functional detox unit and there were also clear-cut reasons for them to be on a mental health unit.  County detox facilities do not take people with suicidal thinking or associated medical problems.  I wonder how many letters it took like the ones I received to permanently disrupt the system so that patients with alcoholism and addictions could no longer get standard medical care.

The end result has been no standards for medical detoxification at all. Some patients are sent out of the emergency department with a supply of benzodiazepines or opioids and advised to taper off of these medications on their own. That advice ignores one of the central features of substance abuse disorders and that is uncontrolled use. Without supervision I would speculate that the majority of people who are sent home with medications to do their own detoxification take all that medication in the first day or two and remain at risk for complications.

Appropriate detoxification facilities staffed by physicians who are trained and interested in addictive disorders would go a long way toward restoring quality medical care to people who have a life threatening addictions.  It would restore more humanity to medicine - something that business decisions have removed.  As far as I can tell, people struggling with addictions and alcoholism continue to be neglected by both federal and state governments and the managed care industry.

George Dawson, MD, DFAPA