Sunday, October 21, 2012

The Besieged Minority

October 25 marks the 10th anniversary of the death of Senator Paul Wellstone.  There was an article commemorating this date  in the St. Paul Pioneer Press today.  Senator Wellstone was a favorite and perhaps my only favorite politician after he voted against HJ Res 114: "To Authorize the Use of the United States Armed Forces against Iraq."  His actual statements about the logic of going to war that are linked to this page is the best example of a rational analysis at a time when there was near mass hysteria to go to war.  And compared to all of the evidence that Iraq had weapons of mass destruction that they were somehow going to use against the US, only his analysis has stood the test of time.  Senator Wellstone is always recognized for his fighting for social causes but I think he also deserves a great deal of recognition for this analysis on the appropriate threshold for the use of force in a high degree of uncertainty.  His analysis in favor of peace.

The article describes the Paul Wellstone Mental Health and Addiction Equity Act of 2007 as his signature legislative accomplishment.  His son Dave lobbied for five years to pass this bill after his father's death and the title of this post is excerpted from a quote from his son:"My dad said that folks with mental illness and addiction were a besieged minority."

Paul Wellstone was certainly right about that.  Anyone who comes from a family with mentally ill or addicted members can attest to the lack of resources and assistance to address those problems.  Those same people can also attest to the uneven insurance coverage or in many cases a complete lack of insurance coverage.  When managed care arrived on the scene about 20 years ago a lot of people had the appearance of mental health and addiction coverage only to see it disappeared when needed based on the managed care company's tactics.  An example would be discharging a person with severe mental illness or addiction in a few days because the "acute" symptoms had resolved and they were no longer "dangerous".

Unfortunately these practices have really not changed.  In many cases they are worse.  Each managed care company has what it calls "medical necessity" criteria.  The best example is acute inpatient care.  A reviewer or case manager reads the chart and decides that the person is no longer suicidal or potentially aggressive to other and decides that they can be discharged.  The discharges occur at a convenient time that allows for somebody to make a profit.  The person's overall stability in terms of their ability to function or whether their personality function has been restored is never taken into account.   The likelihood that they will immediately relapse to a life threatening addiction that has only partially been addressed is not taken into account.  The issue of co-occurring addictions and mental illnesses are not taken into account.  The issue of whether that person is capable of managing any associated medical problems like diabetes is not taken into account.  People are frequently discharged with as many symptoms and problems as they were admitted with.

Practically every outpatient psychiatrist I have talked and corresponded with about this problem has given me the opinion that inpatient psychiatry is for all practical purposes - worthless.  In the meantime, one of the country's largest managed care companies reported last week that their profits were up 26%.

Apart from the loss of Paul Wellstone and the activity of Wellstone Action as far as I can tell there is no current politician out there to make sure that the intent of this legislation will ever be realized.   There is no doubt that federal and state law is extremely business friendly and overtly hostile toward physicians working in the health care system.  The deck is clearly stacked in the direction of health care businesses and the new legislation promoted by President Obama will make things even worse.  Unless there are some valid protections at the level of patient and physician interaction - business decisions based on health company profits will  always trump clinical decisions.  There is no better example than what has happened and continues to happen to psychiatric care over the past two decades.

In the meantime I will remember Paul Wellstone on October 25 and wish that he was still the most unique guy in the US Senate.

George Dawson, MD, DFAPA

Bill Salisbury.  Living On In Those He Inspired.  Pioneer Press. Sunday October 21, 2012.

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