I was out of town at a Mayo Clinic seminar and while I was gone, Amazon sent me an e-mail. My copy of American Psychosis - How the Federal Government Destroyed the Mental Illness Treatment System by E. Fuller Torrey had shipped. This is the only book I have really been eager to read for some time. The title is almost exactly what I have been saying for the past 25 years. At last I had somebody who was finally seeing the real problems with the treatment of mental illness in this country. After putting up with obnoxious blogs about how psychiatrists had been bought and paid for by drug companies, manufacturing catastrophes designed by psychiatrists like the recent DSM-5 apocalypse, and an endless number of side shows I was looking for an anchor point that looked at the real problems and what to do about them.
For the purpose of this post I was interested in one thing. What did Dr. Torrey say about managed care? As any reader here should know by now I view managed care as the single worst thing (by far) that has happened to psychiatric care and the treatment of severe mental illness in the United States. Managed care tactics are responsible for decimating psychiatric care, especially hospital based care. Managed care has destroyed psychotherapy and removed practically all of the creativity and innovation from mental health care. Managed care has rationed both access and treatment resources to my patients who have few resources themselves. In order for this book to impress me, it would need to say something about managed care.
Turning to the index there were exactly two pages about "managed care organizations". What exactly did Dr. Torrey say? The introduction to the section is introducing Medicaid as "the largest single fiscal impediment to improving services for mentally ill persons in the United States." The system is gamed by the states to optimize Medicaid reimbursement by the federal government. The example given is the IMD (institute for mental disease) exclusion that disallows Medicaid reimbursement for state hospitals. The states responded by closing down state hospitals and shifting admissions to Medicaid covered acute care settings in community hospitals. According to Torrey cost shifting based on Medicaid has been the driving force behind public services for 40 years.
Managed care enters the picture in paragraph 2: "At least 34 states deliver 'some or all mental health services through managed care arrangements, including care outs and comprehensive managed care organizations (MCOs). States such as California, Utah, Colorado, Pennsylvania, New York, and Massachusetts have used capitation funding, under which providers are paid a fixed amount to deliver all necessary services." Throw Minnesota in there. And also throw in the idea that practically all states ration using managed care strategies to save money - even if there is no formal contract with an MCO.
He goes on to outline the three features that these programs have in common (my comments in italics):
1. The priority is cost savings and not patient care.
Yes! Managed care has nothing to do with increased access or quality. It is all about rationing access to care including access to medications necessary to treat severe mental illness. There is a reference from the NEJM from 1994 that illustrates that rationing these medications has an unfair impact on patient with severe mental illness and increases overall costs but the industry continued the practice unabated despite that study. Cost savings after all is just a politically correct way to designate profits for the MCO. After all, nobody ever realizes any savings in health care it just ends up on the bottom line of the MCO, the pharmaceutical company or the provider.
2. The sickest patients suffer the most under managed care rationing.
Yes! It should be fairly obvious that if you move the group of patients with the most severe problems at a high rate into a rationed system, they are getting proportionately less resources than the severely disabled of any disease category. Dr. Torrey points out that individuals with severe mental illness represent only 11% of all Medicaid beneficiaries but they are 1/3 of all of the high cost beneficiaries.
3. This is a very profitable segment for managed care companies.
Yes! The example given in the book is United Behavioral Health and their claim to 'oversee behavioral health benefits for more than 23 million beneficiaries' including Medicaid patients. He goes on to illustrate the the difference in outcomes for executives of these companies and the mentally ill whose benefits they oversee and points out that the difference in patient outcomes is directly related to that disparity. (see par 19).
He goes on to conclude that the PPACA (aka Obamacare) will change nothing basically because: "It is likely to lead managed care companies finding new and creative ways to not provide services to mentally ill individuals who need the services the most." Talk about innovation.
I could not have said it better myself, but have said it in a number of ways in the past 20 years. I plan to continue to read and analyze this book. I have already purchased it and can certify that the managed care section is accurate if brief. Any objective observer realizes that the government paying the managed care industry for not providing services is the central problem with the provision of treatment to persons with the most severe forms of mental illness. These days it also extends to more common anxiety and depressive disorders treated in a primary care clinic and diagnosed by a very brief screening.
Keep that in mind when you are reading the latest trivia about the DSM, the pharmaceutical industry involvement with psychiatry, debates about clinical trials data for FDA approval, or any number of psychiatric non events that are furiously debated around the Internet. Tax dollars given to an industry to ration services is money that should have gone to provide services to the mentally ill.
George Dawson, MD, DFAPA