Wednesday, March 11, 2015

NAMI and the Clinton Foundation Take The Bait On Managed Integrated Care

My views on "integrating" behavioral health and primary care are fairly well known.  They run counter to everyone including the American Psychiatric Association (APA) who has been promoting the advantages of "collaborative care".  I use quotes here to designate loosely defined terms that have multiple meanings to different special interest groups.  I should have also included the term behavioral health because outside of managed care companies, the word really has no meaning.  I got a post today in my Facebook feed that stated  The Benefits of Integrating Behavioral Health into Primary Care.  I encourage any interested readers to search directly for this page on the NAMI web site and take a look at the content.  It is in press release format that contains little detailed information.  It presents the chronic disease concept and how chronic diseases cause mental illnesses and make them worse.  It talked about practice models that look at putting therapists in clinics.  It talked about a model that brought a mental health clinician into immediate contact with a patient and clinician in a primary care physician's office, but stated that model lacked sustainable funding.   It talked about the promise of telemedicine.  Since this was a NAMI event, stigma and destigmatization were also on the agenda and the release ends in a global statement about how this will lead to everyone admitting that mental illness affects us all and at that point the stigma will evaporate.

With all of that good news, what do I have against this love fest for integrated care?  Just responding to the news release there are obvious problems with the ideas being mentioned.  The first is that many of these ideas have been around for at least 30 years.  I was hired as the medical director of a community mental health center in 1986 and part of what I was supposed to do was telemedicine through a cable TV and satellite hook-up in the town that I worked.  That never materialized.  Granted the resources today are much more sophisticated, but how many primary care clinics are really going to dedicate resources so that their patients will be seen in their clinic by an outside mental health clinician?  And what about the cost of those services?  There are currently networks of mental health clinicians eager to do telemedicine, but they are not eager to provide those services for nothing.  The economics of telemedicine is that it needs to be supported and there is no evidence that I am aware of that managed care companies support it.  The Veteran's Administration has supported it in some areas, but most health care facilities are not funded like the VA.

Putting therapists in clinics has occurred for more than the past 30 years.  Part of the problem is what those therapists will be doing in those clinics.   Will they end up doing acute assessments for suicide or aggression risk?  If they do identify those problems, are patients going to be cared for in those clinics or sent somewhere else?  In today's landscape of having no functional psychiatric units, will the primary care clinic now start to accumulate people with acute, subacute, and chronic suicidal thinking? Will there now be security issues related to the same problem with aggression?  Is the expectation in these clinics going to be follow up in 3-6 months like many other medical problems?  Will there ever be any effective therapy done?  Psychotherapy after all is probably a better treatment than all of those patients being put on antidepressants for acute adjustment disorders and grief.  Most people in those circumstances notice little effects from the medication.  Psychotherapy is after all a better treatment than benzodiazepines for most people put on those medications for situational anxiety and insomnia.  Therapists can do great work, but they are also rapidly saturated when they have to see patients for 6 - 10 sessions in follow up.  Is there really a managed care company who is going to put enough therapists in a clinic to do some good or are they going to be there just for looks?  You know - look here is the therapist for our integrated model.  Isn't it great?

There seems to be a collective amnesia about how this integrated care model really works and what it is really about.  This is really about continuing to ration care for mental illness and psychiatric care.  Refreshers on that can be found here and here.  Giving everyone in a primary care clinic a very basic screening checklist for anxiety and depression is one of the basic paradigms for all of the integrated care advocates.  The patients mentioned in the press release will be especially likely to score positive on these screens.  That is true not because they magically developed a new anxiety or depressive disorder, but because they have complicated conditions that are associated with anxiety and depression.  If a person has paroxysmal atrial fibrillation when their heart rate suddenly accelerates to a rate of 220 beats per minute, they tend to get very anxious both during those episodes and anticipating the next one.  The same thing is true for patients with heart attacks and emphysema.  Is checklist screening a good enough approach for these patients?  Is following a certain protocol with antidepressants a good enough approach with these patients?  So far, the checklist implementation of the "integrated" approach is a low quality assembly line approach that guarantees more exposure to antidepressants  and a limited differential diagnosis of what else might account for any psychiatric symptoms.  At least one group has determined that broad "screening" for depression (also mentioned in the press release) - does the exact same thing and is generally not a good idea.

This is really all about the money.  Managed care organizations and governments are still very interested in providing the appearance of care for mental disorders and that is about it.  In order to believe that they have some grander plan, an extremely naïve approach is required.  The last thirty years of managed care would need to be ignored.  That history would include the elimination of functional detoxification units for addictive disorders, the general elimination of psychotherapy, restricted access to psychiatrists and limiting psychiatric treatment to a 20 minute "med check", the elimination of functional inpatient units where difficult problems can be treated in a safe and humane environment, the elimination of resources to treat patients with severe aggressive behavior, and restricted access to medications that people may need due to their unique treatment requirements.  The basic concept that managed care was invented and supported by the federal and state governments would also need to be ignored.  The ultimate result of having record numbers of people with mental illnesses incarcerated rather than receiving appropriate care for mental illness cannot be ignored.  Even as I typed this paragraph additional evidence was building to support my theory that this is a huge subsidy for the insurance industry.  A colleague recently posted that there is no "out of network benefits" in New York State and she discusses the ramifications for psychiatric care and psychotherapy.  I see this as a flat out continuation of government sanctioned rationing of psychiatric services by the managed care industry.  They may want you to go to an integrated care clinic, complete a checklist and take an antidepressant rather than seeing your regular outpatient psychiatrist who is providing more than a medication.

Handing someone a depression checklist when they come in to a primary care clinic to get their blood pressure checked is reminiscent of the 1990s approach to pain as the "fifth vital sign", and we all know how well that turned out.

A final word about the stigma buzzword.  What is more stigmatizing - giving you the medical resources that you need for recovery or having you come to a primary care clinic where those resources will probably not be available and practically nobody in the clinic has experience working mental health problems?

That is the basic case against integrated care or what is sometimes referred to as collaborative care.  At this point like everyone else I will be leaning back and watching it unfold.  The insurance industry and government has so much power they can essentially do whatever they want now.  We seem to have a national political forum in health care that leads to an endless stream of bad ideas.  And it seems like we always listen to that endless stream of bad ideas rather than anyone who might know what they are talking about.

George Dawson, MD, DFAPA


  1. Great post. I love how these wonks rehash old tired ideas with a fresh spin and call it innovation.

    The APA/Lieberman version is even worse because it totally eliminates direct patient contact with mental health in a consultant role. Which ultimately ends up being just the opposite of primary care. It's distancing to the point where you ultimately might be replaced by software.

    The other thing is that primary care is in big trouble conceptually and economically. I see nothing wonderful about hitching a wagon to a dying horse.

  2. Agree and a lot of those bad ideas go right back to the Clintons and the famous Task Force on health care led to some degree by this guy:

    "Paul Elwood, a leading member of the White House task force: "insurers-controlled HMOs, under managed care competition will stimulate a course of change in the health care industry that would have some of the classical aspects of the industrial revolution -- conversion to larger units of production, technological innovation, division of labor, substitution of capital for labor, vigorous competition and profitability as the mandatory condition of survival"

    Kind of hard to have any competition if all of the managed care companies decide that a certain treatment is optional and decide to starve it out or transfer it to the corrections system. The statement about survival is quite dramatic when you are funding an industry with a large hidden tax. It is more like a license to make money by denying health care.

    1. The last thing they have to worry about is competition or survival. The big five are like Goldman Sachs, firmly in the guaranteed profits/too big to fail camp.