Showing posts with label bureaucracy. Show all posts
Showing posts with label bureaucracy. Show all posts

Monday, April 18, 2022

Committees and Stakeholders

 


I wrote this editorial in 2010 for the Minnesota Psychiatric Society newsletter Ideas of Reference as part of my role as the President at the time. It was subtitled: "A new approach is needed and I think that approach needs to be psychiatrists redesigning the system."  Since then, things continue to go in the wrong direction. I still find the term "stakeholders" to be cringeworthy. The only stakeholders as far as I am concerned are physicians, patients, and their families. 

 

Who are the real stakeholders when you are face to face with your patient and you are being coerced into doing something that is not in the patient's best interest? Where does the profession stand on this? For almost two decades now we have been complacent while insurance companies, government bureaucrats and politicians, and pharmaceutical companies have directly intruded on the physician-patient relationship in a way that has seriously impacted the resources available for patient care and the quality of that care.  The operative word is complacency. I still have a habit that I learned from my freshman English composition professor. I compulsively look up word definitions to make sure I am using them correctly. I think you develop a lot of insight into your changing knowledge base when you look up words that you think you know very well and find that they seem to have taken on more important meaning. For me complacency has become such a word. Looking it up in several dictionaries, the definition I like the best is: "self-satisfied and unaware of possible dangers". With few exceptions, that seems to be the position we have been in for the past 20 years.

I can't think of a better word to describe how physicians were duped into believing that an RVU based pay system would somehow result in better reimbursement for cognitive specialists. Or that coders could determine who was submitting correct billing based on documentation, much less committing fraud. Or that utilization review for inpatient stays and prior authorization for medications is a legitimate practice. Or that managed care com­panies and behavioral carveouts reduce health-care inflation. Or that the focus of psychiatric assessment and treatment involves the prescription of a pill in roughly the same time frame that an antibiotic could be prescribed for otitis media. The list of things that we've been complacent about is long and it is growing every day.

For those psychiatrists working in institutions, committees are often a starting point. Much of the time, committees and meet­ings focus on issues that are peripheral to patient care and quality care. They rarely focus on the actual practice environment for the psychiatrist and the patient. In many cases, the fatal flaw is that the people making the major decisions are not in the meetings. The meetings are frequently held to make it seem like physicians actually have input into what is going on. At times the physicians are prepared by someone telling them that the old days in medicine are dead. The implication is that physicians used to be all powerful, now they are not, and in fact they should expect to have the equivalent input of any other employee.

The strategies we have observed for dealing with a broad array of stakeholders at the table have all been inadequate. We have allowed stakeholders with clear conflicts of interest to suggest that we are more conflicted than they are. The only solution is to be clearly differentiated from everyone else. We are squarely focused on assessing and treating patients in an ethical manner and any political initiative that we endorse or participate in should be consistent with that focus.

What does this mean in a practical sense? First off, it means coming into a meeting with a clear position rather than showing up to broker a deal. It means prioritizing patient care over profits from rationing or political gain from rationing. It means pointing out that the physician-patient dyad is in no way equivalent to any other political agenda in the room. It means not signing off on the status quo when we are the only people in the room speaking to the interests of physicians and their patients.

The recent changes to the way that psychiatric care is delivered to the state's low-income population illustrate all of the problems. Patients with GAMC have significant psychiatric comorbidity, and, even prior to the cuts by Governor Pawlenty, were also subjected to more rationing by private and government payers than other patients. The ultimate change, in the form of Coordinated Care Delivery System (CCDS) clinics, takes this rationing to a whole new level. At the same time the state has attempted to reinvent the state hospital system. Both of these changes disproportionately affect patients with severe mental illness. Any rational analysis would show that these patients did not have enough treatment resources before the new rationing initiatives. A new approach is needed and I think that approach needs to be psychiatrists redesigning the system. That needs to happen through the MPS because we have psychiatrists with the knowledge and focus to accomplish this task. Rather than endorse a rationed and blended version designed by people who are not providing the care, psychiatrists need to articulate a clear statement of what public mental health should be like in the state of Minnesota.

 

George Dawson, MD, DFAPA

Friday, November 13, 2020

The Bureaucratic Takeover of American Psychiatry

 




This interview was posted on the Psychiatric Times web site today.  It contains bit and pieces from blog posts here over the past 8 years. It is a rare opportunity for people to see what is wrong with American psychiatry and that is - it is not run by American psychiatrists. It is run by managed care companies, pharmaceutical benefit managers, and government bureaucrats who all have the common goals of restricting access to psychiatric services.  And by psychiatric services, I am including substance use disorders and their treatment as well as the considerable amount of treatment of organic brain disorders that is provided by psychiatrists. 

I expect that some people will say: "What is special about psychiatry? Aren't these same rationing techniques applied to all of medicine?"  To a certain extent that is true.  Primary care physicians, medical specialists, and surgical specialists have to contend with similar rationing techniques.  It is however a question of scale.  I have talked with physicians who were around when the psychiatric rationing started and psychiatric services were chosen as the target of the express purpose of elevating the stock price of a company.  I was there when the Hay Report was released in the 1990s showing disproportionate rationing of psychiatric services relative to any other specialty.  I saw the original figures released in 2002 showing that Cardiology services were reimbursed at a 20% premium, while psychiatric inpatient services were discounted by 60%.  That led to some immediate closures of psychiatric hospitals and a continued trend of lower and lower bed availability.   There are endless examples of this disproportionate rationing on this blog and as I point out in the interview it is one of many reasons I write this blog.

One of the key questions that any observer of psychiatry should ask themselves is: "Why is George Dawson the only guy writing about this issue?"  Apart from the fact that this rationing has impacted my care of patients nearly every day of my professional life there are some obvious considerations.

1.  The people who self identify as the critics of psychiatry - clearly know very little about the practice environment or its constraints. I have seen two articles now that use the same example that psychiatrists believe that every mental disorder should be treated with a medication and that this is biological psychiatry.  The model of care they are referring to is not how psychiatrists are trained (see the above figure).  It represents a blended government and managed care model of how patients are scheduled, seen, and billed.  That bureaucratic model at one point employed an M code meaning a 5-10 minute visit with a psychiatrist.

2.  The critics similarly ignore highly innovative and individualized therapies that were invented by psychiatrists such as the Assertive Community Treatment  model that I mentioned in this interview as well as the myriad ways that psychiatrists have figured out how to talk in therapeutic ways with patients in rationed time slots and how those relationships result in recovery.

3.  The critics systematically ignore the lack of infrastructure to support psychiatric treatment.  There are very few inpatient units in each state that allow for the treatment of people with severe mental illnesses. By contrast, there appears to be no shortage of state-of-the-art facilities to treat heart disease, cancer, and gastrointestinal problems.  There is no shortage of state-of-the-art surgical facilities to treat any condition where surgery may be indicated.  In the mean time, mental illness and substance use disorders are the number 1 debilitating disease condition in the United States.  Rather than invest in the necessary infrastructure to provide an equivalent level of care, people with severe mental illnesses are incarcerated instead.  Rather than reversing that trend, several Sheriffs in the country propose designated parts of county jails as psychiatric hospitals and treating people in jail who should not have been incarcerated in the first place. 

I could keep going with additional points like I have in the past, but at this point would encourage any interested reader to take a look at the interview at this link.  Then take a look at the summary at the top of this post and consider my point. Psychiatrists are well trained to do a lot for people with mental illnesses and substance use disorders. We want our patients and their families to have access to the same amount of resources that other medical or surgical specialists have. Don't accept any criticism of psychiatry that does not address these basic points.  


George Dawson, MD, DFAPA 


Reference:

Awais Aftab, MD.  The Bureaucratic Takeover of American Psychiatry: George Dawson, MD, DFAPA
Psychiatric Times.  November 13, 2020    Link


Supplementary 1:

Dr. Allen's comment made me realize a critical deficiency in my graphic and also the interview and that is impact on the academic environment. One of the most exciting aspects of medical school and residency was learning to understand the medical literature and apply it to patient care. I met hundreds of physicians and colleagues with their own unique approaches. In training environments in the 1980s and early 1990s the expectation was that you were researching and reading about your patient's problems and diagnoses and were prepared to intelligently discuss it.  As an attending you had to keep on top of the literature to be a competent teacher and also as a marker of professional competence. Teaching rounds, grand rounds and other teaching based meetings were the most exciting aspects of going to work each day.  I modified my managed care timeline to illustrate the impact on the academic side of the work environment.