Sunday, June 9, 2013
Why reform of the mental health system is hopeless.
I debated putting "reform" in quotes. The term has essentially become meaningless. I have been hearing about health care reform for over 20 years and things continue to get worse and worse. They get worse at a much faster rate whenever mental health care reform is considered. I won't belabor the facts that I have already listed here before, but I witnessed an event yesterday to highlight why any reform of the mental health system is completely hopeless at this point.
The event was a panel discussion entitled "Many Perspectives on Patient-Centered Care and Building a Stronger Mental Health System". There were 5 panelists including two psychiatrists, a local celebrity, a reporter, and a mental health advocate. It was scheduled as a one hour event and I left at about the 1:05 point. The hour began with the panelists disclosing their personal experiences with the system and what that seemed to imply for reform. There were stories about a system that is fairly refractory to input. Psychiatrists can't get people hospitalized when it is a true emergency, the family can't get input into the clinicians treating their loved ones, and there is minimal if any cross talk among physicians. There were two stories of misdiagnosis, in one case over a period of 20-30 years. The problem of documentation came up and the fact that there seems to be "no narrative" any more about the patient's diagnosis and problems - only check lists and electronic health record forms.
After the initial presentations the audience got involved. The audience was essentially all psychiatrists and the solutions were predictably more infuriating anecdotes, workarounds, and tales of the one unique person who might be able to save the day. From the panel, the advocacy standpoint seemed to be that progress was being made and that no more hospital beds were necessary or at least they should be discussed as an absolute last resort since they are the most expensive treatment option. That discussion focused on a point by an audience member who I would consider to be one of the top experts in child and adolescent mental health in the state when he mentioned there were only "2.5 acute care beds in the State" available for children in crisis. I may have missed the actual solutions because I had to leave the meeting. I have seen meetings and panels like this before and they go nowhere.
So what is the problem and what can be done about it?
The problem is quite simply managed care and all of its permutations. I waited for 65 minutes and nobody uttered the word. Managed care and all of its special interests is directly responsible for the ridiculous time constraints on clinicians. There is no time for a complex diagnostic evaluation much less time to talk with the family. It is responsible for the rationed inpatient beds and the lack of bed capacity. It is responsible the fact that systems of care are set up to optimize cash flow to large health care organizations rather than the quality of care. There is perhaps no better example than what currently passes for inpatient psychiatric care. We currently have case managers running the care of hospitalized patients and telling their psychiatrists when to discharge them. I talked directly with an inpatient psychiatrist the other day who told me that case managers and social workers at his hospital frequently have the discharge plan set up before he sees and assesses the patient. They simply tell him that the patient can be discharged. All in the service of making sure that nobody extends beyond the DRG payment and the hospital continues to make money. Inpatient units seem to have become holding tanks for people to sit around until they are "cleared" for discharge. That typically involves sitting around on a secure psychiatric unit and answering questions about whether or not you might be "suicidal" until you can be released. All of this flows from the ridiculous managed care concept that "dangerousness" is the only reason people need to be on a psychiatric unit. All of that occurring at a time when mental health advocates are concerned about stigmatizing the mentally ill as violent. Is it possible that psychiatrists have become so hopeless about reversing the trend of business friendly but otherwise irrational rationing that they avoid even talking about it anymore? I think that is more than likely.
Outpatient care is not much better. Some of the panelists were talking about the virtues of outpatient care where there is a team that knows the patient and everything is idyllic. There is no reason to expect that an outpatient case manager is any more virtuous than an inpatient one. I have talked with many psychiatrists who notice that their care is basically completely marginalized by low to mid level bureaucrats who have no professional responsibility to the patient. I have be pointing this out for 20 years and recently other physicians are also talking about the problem.
As long as you pretend that making money off rationing your care and treating you is not a conflict of interest - the system will continue to deteriorate. As long as nobody acknowledges that psychiatrists have been looking at "cost effective" care in the rear view mirror for the past 20 years - reasonable change is impossible. As long as nobody in the room can clearly say "First of all there is no system and second, managed care and the associated rationing and low quality are the real problems here" - reform will remain meaningless political rhetoric.
George Dawson, MD, DFAPA
Jerry A. Singer, MD. How Government Killed the Medical Profession Reason May 2013.