Sunday, September 13, 2015

Is Mental Health Legislation Really The Joke That I Think It Is?

The above graphic is a headline search of mental health parity going back to 2004.  I was in the thick of things from 2009-2012 as the transitioning President of a District Branch of the American Psychiatric Association - the Minnesota Psychiatric Society.  Not that it gave me the inside track on anything.  I think officers in district branches spend most of their time trying to get members motivated to do something.  My strategy was basically to approach things in the way I do on this blog.  I don't think that is was any more or less successful than the dialogue promoters, but at one point some people became uncomfortable when I suggested that one of the hospitals could have been managed better.  It was apparent to me at that time that professional organizations do not tolerate disagreement very well.  As far as I can tell, there can be no real changes in organizations without disagreement and disagreement should be expected anytime there are people who want to talk endlessly and people who want action.  On the other hand nobody has to take it personally.  That may not be possible in Minnesota or in professional organizations.  I have previously referred to it here as the "big tent" approach where multiple goals are tolerated even some that conflict with the overall goals and ethics  of the organization.  An example would be prior authorization of medications.  The vast majority of members find it extremely intrusive and a waste of their time, but the members who are executives in managed care organizations do not.  Accepting both of those positions is a tacit acceptance of prior authorization while working with the members to change it.  How do you think that will work out?

Parity or equal coverage for mental illness and physical illness was a legislative initiative of two U.S. Senators Paul Wellstone and Peter Domenici.  Both had personal experience with the problem having family members with severe mental illness.    That personal experience remains critical in the political and cultural landscape.  There are still plenty of people pushing the "myth of mental illness" fallacies.  Some have moved on to just blame psychiatrists.  People with experience recognize those arguments for what they really are and can try to proceed with real solutions.  I never met Paul Wellstone, but I liked him a lot.  He was one of a handful of US Senators who voted against authorizing the invasion of Iraq based on the flawed weapons of mass destruction argument.  He was vilified by some for the vote and referred to as an ultra-liberal.  That is a glib characterization during an era where there are no liberals.  In Minnesota he was widely known as a populist.  People perceived him as a common man who cared about the common people.  He was tragically killed in a in a plane crash in northern Minnesota in 2002 while campaigning for his fourth term in the Senate.  Senator Domenici retired from the Senate in 2009, after the longest tenure at that position by anyone from the state of New Mexico.  My guess is that the final form of this bill and the way it is implemented was not the intent of either of these Senators.

I read through several iterations of their bill until it became The Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA).  All of those versions are available on the Congressional web sites, but the factsheet is available from CMS.  It should be fairly obvious by any casual read of the factsheet that there are so many exceptions and vagaries associated with this law that it would not take the insurance industry and their government affiliates long to shred it.  I pointed this out at the APA 2011 Annual Meeting in Hawaii.  There was a meeting about how the MHPAEA was going to revolutionize the care of people with addictions.  A prominent psychiatrist and government official was scheduled to be there to explain how this was going to happen.  At the time, the impact of the law was not apparent on any of the acute care services where I was working.  At the meeting after listening to an overenthusiastic presenter explain how funding all of these programs were going to greatly increase bed capacity and services for all, I asked the simple question: "What would prevent any managed care company from providing a screening test and calling that assessment and treatment?"  The answer was "Nothing would prevent that."  No elaboration.  No discussion of how employers can just opt out of mental health and substance use treatment.

That introduction allows me to flash forward to the current time.  I was recently interested in referral for an acute psychiatric hospitalization in the Twin Cities - a metropolitan area of 3.8 million people.  According to a 2007 state report there were a total of 563 acute care beds for that area or 14.8 beds per 100,000 population.  According to the Organisation for Economic Co-operation and Development (OECD), the US ranks about 30th of 35 ranked industrial countries in terms of psychiatric beds per 100,000 population and the Minnesota metro is significantly below the US average of 25/100,000.   Based on those factors it should not be surprising that I was advised that there were no available beds and that the emergency department we could refer to had a 30 hour wait for assessments.

Compare that to Cardiology services in the same area.  Any middle-aged person (or younger) with chest pain would be immediately admitted to a coronary care unit or telemetry and have a standard evaluation completed even if they were discharged or undergo emergency catheterization and angioplasty/stenting.   I have never heard of a wait for acute Cardiology services.  I have never heard of a 30 hour wait in the emergency department for Cardiology services.   My point here is that the MHPAEA or parity legislation has done exactly nothing for the availability of acute psychiatric services.  These same numbers and waiting times in the ED have been there for the past 15 years.  There is no parity as long as there is no equal funding, and mental health services are funded at a fraction of what Cardiology services are.  Walk through any modern Cardiology Department or Heart Hospital and ask yourself: "Where are the equivalent psychiatric or mental health services?"  There are a few exceptions but generally not many and even then, a new facility is still managed by rationing strategies that result in people being discharged with inadequate plans and before their problems are completely addressed.  Inpatient psychiatric services are in effect behind a firewall and accessible only through the bottleneck in the ED.

The grim picture of acute care mental health services is only exceeded by the state of acute care addiction services.  As early as 1988, I was being advised by managed care companies that I could not detoxify patients with alcohol dependence on inpatient psychiatric units,  even if they had significant psychiatric comorbidity like suicidal ideation and depression.  The picture has gotten progressively worse since then.  It is common practice these days to send alcohol dependent people home with benzodiazepines and expect them to manage their own detox.  The lack of functional detoxification services keeps many people in the cycle of addiction to benzodiazepines, opioids and alcohol.

Confirmation of my skepticism about parity came in the form of the Mental Health Reform Act of 2015.  It is also a bipartisan bill introduced by Senators Bill Cassidy (R-Louisiana) and Chris Murphy (D-Connecticut).   There are House and Senate versions.  Both establish a new assistant secretary position for mental health and substance use disorders under the Department of Health and Human Services (HHS).   The fate of the Substance Abuse and Mental Health Services Administration (SAMHSA) hangs in the balance and getting rid of this highly flawed agency should be a priority.  SAMHSA has been the lead agency for mental health during this time of no parity and has not said anything about it.  The remaining description of the bill has to do with education people about HIPAA (do we really need that?) and insurance company accountability for a lack of parity.  The fanfare for this bill including praise from the APA is the exact same way the parity legislation started.  It should be evidence to every American by now that Congress is really interested in appearing to do something and appearing to want reform rather than getting the job done.

I don't think that there is anyone in Washington who knows the meaning of the word reform.  Until politicians everywhere realize that mental health services and substance use services have been an easy way for health care companies to make money by denying reasonable services nothing will happen.   It would help legislators to realize that they also have the highly flawed idea that managed care actually saves money and it is a conflict of interest for them to continue to promote this middle man on that basis.  I am not holding my breath, but it should be obvious that when a reform bill happens every 7 years, and there are still 30 hour emergency department waits and no acute care beds for admissions - there is no parity and there has been no reform.

George Dawson, MD, DFAPA



  1. The promise of parity has remained just that, an unfulfilled promise.

  2. What mental health legislation passed in our lifetime has been effective?

    I'd focus on getting treatment to the most seriously ill first, then worry about parity later. The problem with putting parity front and center is that from a utilitarian and public health standpoint, you have to take care of the big stuff first. And the first is realistic while the second is not.

    Adjustment disorders and NOS conditions are never going to be reimbursed like retinoblastomas and end stage renal disease.

    1. Part of the problem is that they are currently reimbursed nearly the same by the DRG system. As an inpatient doc, most of the college age students admitted in crisis for suicidal ideation are likely to be in this category rather then a major mood disorder or psychosis. They are allowed similar reimbursement as the catatonic person who is unstable, requires additional staffing and is in the hospital for a month. The person with severe illness is generally treated at a loss in our system of care, based on faulty assumptions that favor payers.

  3. My observations from inpatient units (child thru geriatric psych, addition/substance abuse treatment) in two states, over the past 20 years, is that limitations on the quality of care are dictated by the payers who obviously have a symbiotic relationship to pharmaceutical companies. The standards of care and/or treatment guidelines that have been carved in stone by highly suspect academics with notable COI, prevail over nearly all non-drug interventions. On the front lines as a professional who was supported by management a decade ago to expand and refine my practice via cutting edge course work and training, I can add that there were significant barriers to transforming the culture around the biomedical model of care. There was also a curious absence of support from management that translated as superficial endorsement of what became known as "window dressing" to assuage JCAHO's concerns about quality of care based on patient satisfaction surveys. It was also considered part of a marketing strategy to sell "recovery" and "trauma informed care" models that never had a chance to get off the ground. Challenging anyone in administrative roles on this disparity of evidence to back up the advertised new approach to inpatient treatment, automatically put one's employment status at risk.
    An outcome of this pretense on the part of mangers and administrators, was loss of motivated, dedicated to excellence MH professionals by two different mechanisms. !) Termination of employment for being a trouble maker, or whistle blower 2) Resignations from staff who were dissatisfied with their non-professional roles. Now, on many of these units, the moral of staff is as low as the turn over rate is high. Somehow, the longer term effects of coercing professionals to compromise their integrity and participate in a model of care that was beginning to look more like abuse than treatment was never fully contemplated. The drug based model, though lucrative and incentive based for many MH professionals, has produced longer term costs. Could it be a simple matter of the expense of doing the wrong things for the wrong reasons? I think it is a least worthwhile to ponder how the most expensive treatment- acute care on inpatient psychiatric units is the most highly criticized and least desired setting for most people with what are termed, "severe mental illness".
    Simply stated, a thriving business has satisfied customers and a reputation that sells itself. The business of Intensive psychiatric treatment has more dissatisfied consumers, and a negative reputation that isn't yielding to the APA's propaganda. I've heard state officials comment on the financial liability of inpatient psychiatry-- short and long term. And whenever budgets for MH services are cut, the best clinicians and front line staff are thrown overboard, like dead wood on a sinking ship. The captains of industry remain at the helm awaiting a fresh crew. Budget saving newbies, whose illusions and ideals are still intact, and veterans of the system who are blissfully institutionalized to expect the worst.
    Is there another way, other than bucking the system and taking the risks any pioneer invariably faces, to provide the kind of care that is valued ? -- and therefore, valuable.

    1. I would have to disagree with one of your premises. I ran an inpatient unit for 23 years that specialized in treating patients with a high degree of complexity and was on two P&T Committees governing the use of pharmaceuticals in those organizations. Managed care really has no relationship with these companies other than contracting to get the best possible deals. After reading all of the ranting about Big Pharma on other threads it seem they are talking about some academic departments, possible in the early days where there was not much managed care penetration.

      The managed care approach to inpatient is quite simple and I can break it down to a few rules:

      1. Get everyone out in 3-5 days and in less time than the standard reimbursement for the most common DRG. The last reliable information I have is that fee was about $4,000.

      2. Establish a vague "dangerousness" criteria that really has little to do with patient need to rationalize precipitous and irrational discharges discharges. A good couple of examples from my experience: the patient has not "said" that they were "suicidal" today and therefore they can be discharged, or the patient does not have access to that firearm int he hospital so they can be discharged. At some point the external utilization review process can be internalized to that it is run by employers making it even more difficult to resist.

      3. Do not do adequate detoxification on anyone if you can get away with it. Send people out to non-medical county detox facilities that are so aversive that anyone with any judgment would leave. Do not admit anyone who needs complicated detox to the units because their stay easily outruns the DRG payment.

      4. Do not allow psychiatrists to be involved in the admission process, because it would strand hard to place patients in other areas of the hospital (ED, Med-Surg units) and those departments would complain that they are subsidizing the psych units and that is unacceptable to these department because it would add to their length of stay.

      5. Stamp out dissent - as you point out, it is quite easy to scapegoat anyone who disagrees with this charade or has the audacity to point out that making up standards as they go along is really not Evidence Based Medicine.

      It turns out that inpatient psychiatric care is really NOT expensive and that is the real problem. It s cheaper to try to send somebody to an inpatient psychiatric unit and hope they get stranded there than paying what it really costs to care for them in the community. Payers are paying the $4,000 DRG payment no matter how long the patient stays. Typical group home rates can be much higher than that and of course not many of them exist either.

      Outpatient care is also not funded much better. The new federal rules will include a rule that you will get slightly higher reimbursement if you are in a collaborative care clinic. Existing rates in many cases are pathetic and that drives the managed care ideal of productivity and seeing too many patients for too brief a period of time with a focus only on medications.

      I don't think that Big Pharma can be blamed for managed care. Both managed care and Big Pharma are courtesy of naive politicians at the federal and state level. The effects of both are deleterious to psychiatric practice and the APA is politically inept in dealing with the problem.

  4. Why, then, won't payers reimburse inpatient stays based solely on clinical professional judgement of patient needs? UR always seems to focus as much on stabilizing a patient via medication changes, as they do on a patient meeting criteria for safe discharge. (both can be tweaked to support a longer stay for other than stated reasons)-- I am totally in favor of judicious use of medication, patient teaching to gain assent to treatment / informed consent, and medically monitoring patients for adverse responses to medication when new meds are started or dosages are significantly changed. Why does it always seem that the attachment to a drug centered treatment model prevails, and the dissenters to it are always the first to go?

    1. It really was never a question of professional judgment.

      Even without utilization review, most psychiatric services are reimbursed so poorly that you can run inpatient units only two ways - try to get people out in less time than the ridiculous DRG window or "subsidize" psychiatry from other services.

      Don't forget about ridiculous "productivity" expectations and not enough time left for a normal life if you happen to be an inpatient doc.

      If any insurance or managed acre company is honest, UR is completely unnecessary from a business standpoint. If you are a business and you can payout whatever you want to that is all you need to control costs. UR seems to me to be more of a political tool to keep physicians demoralized and give the strong message that the MBAs are in charge and know more than the physicians. Your judgment developed in medical training is irrelevant.

      What happens on units regarding medication depends on the patient population. Your model seems to apply to voluntary patients interested in getting well. In most of the settings I worked people were severely ill, both medically and psychiatrically. The focus was on medicine and their associated medical problems. I probably stopped as many medications as I started and I provided psychotherapy that was essentially on my own time, but these folks were not going to get better with psychotherapy alone and in most cases had seen a number of therapists. There are very few places where psychiatrists are reimbursed to do therapy and even there - you are expected to do it 8 hours a day an do all of the associated paperwork and calls on your own time.

  5. I came into psych after 14 years in medical/surgical- about 5 years acute/critical care nursing ~late 80's early 90's. I did a clinical psych internship at an academic teaching hospital- 1992-93- On this child psych unit at that time, biomedical model was in vogue, and nurses were using psych diagnoses to develop critical pathways , which I had worked with extensively in medicine. Critical pathways are the basis for nursing care plans that focus on discharge goals/criteria at the time of admission. Right away, I saw problems with this in a psych setting. Though not then criticizing the bio model, I found that it was not useful to initiate care plans based on diagnosis--too many variables. However, the strict length of stay reimbursement policies had to be negotiated--- and right from the start of my psych inpatient experience, it was clear that what we said we were doing and what we actually did were worlds apart, treatment wise. It was common practice for the UR nurse to embellish and improvise to get extra days covered--- and it was standard practice for nurses to document patient progress and problems in concert with the expressed needs of the UR nurse--. Things like this were much harder to fudge on a medical/surgical unit. And outpatient support.nursing care, etc. much more readily available ,which expedites discharge--- though usually with some trepidation on the part of the patient and sometimes the nurse as well.
    And then there are the psychiatric diagnosis/symptom algorithm nightmares -- never should have been carved in stone , perhaps--? This is framework for the tons of superfluous paperwork demanded of psych clinicians -- documentation to support billing, virtually worthless in terms of communicating issues of concern and areas of focus for individual psychiatric patient treatment.
    I have strong opinions regarding the biomedical/drug centered psych treatment model , but I am not sharing this specifically to criticize it, as much as to suggest that the more deeply engrained the notion that mental illness is a medical/biological/brain problem, the more it avails itself to assembly line, cookie cutter treatment-- fast track discharge and *any port in a storm* after care. Worse case scenario for psychiatric patients and somewhat upsetting to medical ones, though again, they usually have excellent home care options.
    I could be wrong, but I think this managed care intrusion began as a carrot for some doctors-- I know that TMAP and CMAP played right into it-- and the carrot was the profit from psych drugs as first line treatment. Again, maybe I am wrong, but it seems that the obstacle to the medically ethical recourse, or rather, reform that prioritizes the patient's needs, is financial loss for a powerful few in both psychiatry and pharma.

    1. I can tell you that there was never and I mean never any carrots for me. Not from managed care, not from pharmaceutical companies, and not even from my own administration. Nothing but pain as far as the eye could see. Treating and managing patients on few resources and in a generally hostile environment.

      I still don't get what my financial incentive is when I am earning money in the lowest percentile of any psychiatrist, treating patients in a hostile environment, and treating patients with medical and psychiatric problems that nobody else would manage?

      What am I missing here? How I am a lackey for Big Pharma or managed care when I am simply trying to survive from day to day and some days barely making it?


  6. Just my perspective on the situation you, or any psychiatrist with integrity has to negotiate. I didn't mean to imply criticism of you or your practice. Very much appreciate all you have shared on this topic. What's missing is acknowledgement and respect for the work you are doing.