I guess the magical thinking about how a purely political initiative with absolutely no grounding in science will affect the practice of medicine will never cease. The latest speculation is from the Journal of Clinical Psychiatry and commentary from several prominent psychiatrists (see reference) on "The Effects of the Affordable Care Act (ACA) on the Practice of Psychiatry." I know I have said this before but there is so much wrong with this piece, it is difficult to know where to start.
The centerpiece like most discussions of the Affordable Care Act focuses in integrated care. I criticized the American Psychiatric Association for backing any proposal that relegates psychiatry to a peripheral supervisory position looking at so-called measurements to determine if the clinic population is "healthy" or if they need more treatment (translation = antidepressants). There is weak evidence in this article that this model will be the bonus it promises to be. Care given in the Department of Veteran's Affairs (VA) clinic is given as example of how things might be. A patient seeing multiple specialists may receive care from multiple specialists without personally having to coordinate that care. As a patient at the Mayo Clinic - it has been that way for decades. In fact, if they know you are from out of town they can frequently coordinate that care on the fly so it can all happen the same day! No patient aligned care teams necessary there. Just a good system.
There was a statement about how the ACA could hurt psychiatric care of the seriously mentally ill because the states who previously paid for that care will want to bail out. The discussants point out "although the ACA plans to reimburse certain institutions for emergency inpatient psychiatric care for Medicaid patients, other evidence based practices for treating severe and persistent mental disorders are not usually covered by health insurance." Let me translate that for you. That means there will be even fewer inpatient services. The inpatient care for mental health and severe addictions takes another hit. After three decades of decimation by the managed care industry and that same industry shifting the treatment cost for these severe mental disorders to the state - we are going to pretend that nobody needs these services and continue to downsize. After all, there have been no enlightened managed care CEOs to date who decided that these services were actually important enough to adequately fund. Why would they now that they have the leverage to shift all of the money to the all important Medical Home?
The idea that physicians will be paid by "value rather than volume" had me laughing out loud. I pictured the Medical Home psychiatric consultant poring over the clinic's latest batch of PHQ-9 scores and deciding which patient's antidepressants needed tweaking based on this checklist and the cryptic note of a primary care provider. Will we need more checklists for side effects and unexpected effects on the patient's conscious state? Will we need checklists for neuroleptic malignant syndrome or serotonin syndrome? What about the FDA's recent concern about arrhythmias? Cardiovascular review of systems or electrocardiogram? That will be a lot of paperwork to look over. I wonder what the consultant will be paid for delivering that level of "value". Of course all of the discussants were aware of the fact that most psychiatrists will be employees of some sort or another. Those who have not been assimilated may be in concierge practices or private practice, but good luck interfacing with the ACO.
The all important technology card was played and how that should cause us all to swoon. Online or computerized therapy was mentioned. That modality has been available for over 20 years and not a single insurance company or managed care company has implemented it. Any cost benefit analysis favors an inexpensive assessment (PHQ-9 + low intensity primary care visit) and even less expensive medications prescribed as quickly as possible. The unmentioned tragedy of the electronic health record is how much psychiatric assessments have been dumbed down. The loss of information and intelligence due to the electronic health record is absolutely stunning. Phenomenological elements that require a substantial narrative or interpretation by a thinking psychiatrist are totally gone. All that is left is a template of binary elements that are important only for billing and business purposes. I suppose the lawyers might like the fact that you check the "Not suicidal" box before a patient is hurriedly discharged.
Psychiatry without a narrative or a formulation or a rationale is not psychiatry at all. In the end that is what the ACA leaves us with.
George Dawson, MD, DFAPA
Ebert MH, Findling RL, Gelenberg AJ, Kane JM, Nierenberg AA, Tariot PN. The effects of the Affordable Care Act on the practice of psychiatry. J Clin Psychiatry. 2013 Apr;74(4):357-61; quiz 362. doi: 10.4088/JCP.12128co1c. PubMed PMID: 23656840.
Showing posts with label ACA. Show all posts
Showing posts with label ACA. Show all posts
Thursday, July 11, 2013
Tuesday, June 25, 2013
The Real Problem With Managed Care Research
You know the kind of research I am talking about. The research that shows that managed care is more cost effective and higher quality than fee for service. This stuff has been out there since the 1990s. Is there really research like that out there or is it little more than a political exercise? We have more than a few clues thanks to recent analysis of a Health Affairs article by Kip Sullivan. The article is titled: "The ‘Alternative Quality Contract,’ Based On A Global Budget, Lowered Medical Spending And Improved Quality" Sullivan points out that the title of this article is misleading because it suggests that the managed care intervention here "lowered medical spending and improved quality" in the title, but in the body of the work the authors state:
"Our findings do not imply that overall spending fell for Blue Cross Blue Shield of Massachusetts in 2009-2010."
and a paragraph later:
"This result makes it likely that total Blue Cross Blue Shield payments to groups in 2010 exceeded medical savings achieved by the group that year."
Sullivan's analysis here is dead-on, especially the idea that "medical savings" can be parsed from overall savings when there is suddenly a large managed care infrastructure. From some of the places where I have worked, this means bringing in a raft of middle managers who provide no service and generate no income to "manage' the people who are actually providing the care. In some settings that could mean a "manager" for every 5 - 10 physicians. If your goal is to cut reimbursement to the providers by just paying them less or sending them fewer referrals while adding a costly overhead of a number of managers who think they can translate their ideas about business into better clinical care - that seems like a recipe for higher costs, record physician dissatisfaction, and disregard for professional quality based guidelines. Sullivan points out that this specific problem in managed care research has been around since the 1990's
The "higher quality" issue is as interesting. I encourage anyone interested to download the paper because it is only free until Sunday June 30. As you read it, take a look at the table labeled "Exhibit 4". It is a table of quality care measures across both the control groups and the intervention groups. Although many of the variables are easily defined a couple of issues appear to be clear. Many seem to be process variables. In other words, just keeping track of variables and making sure that you are ticking them off gives you more credit. This is standard procedure in a managed care environment with more case managers. They can literally be assigned to remind physicians or ward teams to do tasks on a time frame that gives them credit for the process variable. More administrative manpower should equate to a larger percentage of process variables.
I note that within the quality variables there are two that apply to psychiatry - Depression: Short Term Rx and Depression: Long Term Rx. There are no significant differences across that study period at the P<0.05 level. This is interesting at a couple of levels. First, if this is actually the number of depressed people treated the change after the managed care intervention is not significant. Secondly, what measures are used to make this determination. Are these actually depressed people or are they patients scoring above a certain cutoff on a PHQ-9 rating scale? Third, is the change in percentage of patients treated a legitimate quality marker? Aren't we more interested in retention in treatment and actual treatment of individual patients treated into remission rather than a cross sectional look at the percentage of patients treated?
The scientific concerns about this paper are numerous. Like all research (and I mean all research) there are political implications. The defined intervention here of the Alternate Quality Contract, is basically a primary care physician as gatekeeper model that consumers rejected over a decade ago. At that point in time, managed care organizations realized that they would need to compete on the basis of providing direct access to specialty care without primary care referrals. The adaption of the MCOs was to hire their own specialists and build speciality clinics. The article describes this as basically the "patient centered medical home" (p 1886). I wonder if the average consumer realizes that the medical home is really a primary care gatekeeper system from the past?
I can't help stressing the importance of article like this one and all research that purports to save money with larger administrative structures that are there in a large part to supervise physicians rather than create administrative efficiencies. There is no better example than the non-existent mental health system for what this kind of rationing and administrative excess can create. Diverting money from the direct provision of clinical care into complicated forms of administrative overhead needs to be measured accurately in all of these studies.
George Dawson, MD, DFAPA
"Our findings do not imply that overall spending fell for Blue Cross Blue Shield of Massachusetts in 2009-2010."
and a paragraph later:
"This result makes it likely that total Blue Cross Blue Shield payments to groups in 2010 exceeded medical savings achieved by the group that year."
Sullivan's analysis here is dead-on, especially the idea that "medical savings" can be parsed from overall savings when there is suddenly a large managed care infrastructure. From some of the places where I have worked, this means bringing in a raft of middle managers who provide no service and generate no income to "manage' the people who are actually providing the care. In some settings that could mean a "manager" for every 5 - 10 physicians. If your goal is to cut reimbursement to the providers by just paying them less or sending them fewer referrals while adding a costly overhead of a number of managers who think they can translate their ideas about business into better clinical care - that seems like a recipe for higher costs, record physician dissatisfaction, and disregard for professional quality based guidelines. Sullivan points out that this specific problem in managed care research has been around since the 1990's
The "higher quality" issue is as interesting. I encourage anyone interested to download the paper because it is only free until Sunday June 30. As you read it, take a look at the table labeled "Exhibit 4". It is a table of quality care measures across both the control groups and the intervention groups. Although many of the variables are easily defined a couple of issues appear to be clear. Many seem to be process variables. In other words, just keeping track of variables and making sure that you are ticking them off gives you more credit. This is standard procedure in a managed care environment with more case managers. They can literally be assigned to remind physicians or ward teams to do tasks on a time frame that gives them credit for the process variable. More administrative manpower should equate to a larger percentage of process variables.
I note that within the quality variables there are two that apply to psychiatry - Depression: Short Term Rx and Depression: Long Term Rx. There are no significant differences across that study period at the P<0.05 level. This is interesting at a couple of levels. First, if this is actually the number of depressed people treated the change after the managed care intervention is not significant. Secondly, what measures are used to make this determination. Are these actually depressed people or are they patients scoring above a certain cutoff on a PHQ-9 rating scale? Third, is the change in percentage of patients treated a legitimate quality marker? Aren't we more interested in retention in treatment and actual treatment of individual patients treated into remission rather than a cross sectional look at the percentage of patients treated?
The scientific concerns about this paper are numerous. Like all research (and I mean all research) there are political implications. The defined intervention here of the Alternate Quality Contract, is basically a primary care physician as gatekeeper model that consumers rejected over a decade ago. At that point in time, managed care organizations realized that they would need to compete on the basis of providing direct access to specialty care without primary care referrals. The adaption of the MCOs was to hire their own specialists and build speciality clinics. The article describes this as basically the "patient centered medical home" (p 1886). I wonder if the average consumer realizes that the medical home is really a primary care gatekeeper system from the past?
I can't help stressing the importance of article like this one and all research that purports to save money with larger administrative structures that are there in a large part to supervise physicians rather than create administrative efficiencies. There is no better example than the non-existent mental health system for what this kind of rationing and administrative excess can create. Diverting money from the direct provision of clinical care into complicated forms of administrative overhead needs to be measured accurately in all of these studies.
George Dawson, MD, DFAPA
Monday, June 17, 2013
Collaborative Care Model - Even Worse Than I Imagined
I wrote a previous post about the APA backing the so-called collaborative care model and provided a link to the actual diagram about how that was supposed to work. I noted a more elaborate model with specific descriptions of roles in the model in this week's JAMA. The actual roles described on this diagram are even more depressing and more predictive of why this model is doomed to fail in terms of clinical care. It does succeed in the decades long trend in marginalizing psychiatry to practically nothing and providing the fastest route to antidepressant prescriptions.
Wait a minute - I thought psychiatrists were the Big Pharma stooges who wanted to over prescribe antidepressants and get everyone on them? Well no - it turns out that there are many government and insurance company incentives to assure that you have ultra rapid access to antidepressants even when psychiatry is out of the loop. You don't need a DSM-5 diagnosis. You don't need to see a psychiatrist. If you pulled up the diagram in JAMA, you would discover that the consulting psychiatrist here has no direct contact with the patient. In fact, about all that you need to do is complete a checklist.
Copyright restrictions prevent me from posting the diagram here even though I am a long time member of both organizations publishing them. I do think that listing the specific roles of the psychiatrist, the care manager and the primary care physician in this model is fair and that is contained in the table below:
see JAMA, June 19, 2013-Vol 309, No. 23, p2426.
As predicted in my original post, the psychiatrist here is so marginalized they are close to falling off the page. And let's talk about what is really happening here. This is all about a patient coming in and being given a PHQ-9 depression screening inventory. For those of you not familiar with this instrument you can click on it here. It generally takes most patients anywhere from 1 - 3 minutes to check off the boxes. Conceivably that could lead to a diagnosis of depression in a few more minutes in the primary care clinic. At that point the patient enters the antidepressant algorithm and they are they are officially being treated. The care manager reports the PHQ-9 scores of those who do not improve to the "supervising" psychiatrist and gets a recommendation to modify treatment.
This is the model that the APA has apparently signed off on and of course it is ideal for the Affordable Care Act. It is the ultimate in affordability. The psychiatrist doesn't even see the patient - so in whatever grand billing scheme the ACA comes up with - they won't even submit a billing statement. The government and the insurance industry have finally achieved what they could only come close to in the past - psychiatrists working for free. Of course we will probably have to endure a decade or so of rhetoric on cost effectiveness and efficiency, etc. before anyone will admit that.
Keep in mind what the original government backed model for treating depression was over 20 years ago and you will end up shaking your head like I do every day. Quality has left the building.
George Dawson, MD, DFAPA
Wait a minute - I thought psychiatrists were the Big Pharma stooges who wanted to over prescribe antidepressants and get everyone on them? Well no - it turns out that there are many government and insurance company incentives to assure that you have ultra rapid access to antidepressants even when psychiatry is out of the loop. You don't need a DSM-5 diagnosis. You don't need to see a psychiatrist. If you pulled up the diagram in JAMA, you would discover that the consulting psychiatrist here has no direct contact with the patient. In fact, about all that you need to do is complete a checklist.
Copyright restrictions prevent me from posting the diagram here even though I am a long time member of both organizations publishing them. I do think that listing the specific roles of the psychiatrist, the care manager and the primary care physician in this model is fair and that is contained in the table below:
Roles in Collaborative Care Model
Care Manager
|
Monitors all patients in the practice
Provides education
Tracks treatment response
May offer brief psychotherapy
Describes patient symptoms and response
to treatment to psychiatrist.
Informs Primary care Physician
of treatment recommendations from the psychiatrist
|
Primary Care Physician
|
Makes initial diagnosis and prescribes medication
Modifies treatment based on recommendations from psychiatrist
|
Psychiatrist
|
Makes treatment (medication)
recommendations.
Provides regular psychiatric
supervision.
Has no direct contact with the
patient.
|
Monday, July 16, 2012
SAMHSA Aligned with Managed Care
When you have been as sensitized as I have to the rebranding of
mental health services as "behavioral health" by the
managed care industry - seeing a government agency promoting that brand is
difficult to take. I got an e-mail from SAMHSA
this morning that does exactly that. The subsequent spin
on behavioral health and health care reform needs to be read to be
believed. It is something that only a government bureaucrat or managed
care administrator could actually believe.
This is an interesting excerpt: "Twenty years
ago, even some in the behavioral health field didn't think recovery was
possible." Maybe that was why they were telling me that people in
the throes of detoxification were now stable after three days. Insisting
that subscribers to their managed care insurance should be discharged home and
that they could go to outpatient treatment despite repeated failures is
certainly consistent with that statement.
Their spin on the PPACA is even more incredible with this
summary statement: "Providers will also face new payment mechanisms such
as capitation, episode rates, and team based payments rather than based on
services provided." That statement alone is proof that nobody at
SAMHSA seems to understand that capitation was the primary mechanism that
managed care used to dismantle mental health and addiction services to the abysmal
level that they currently exist at. Either that or they understand
perfectly.
This web page confirms what I have been saying for the past
twenty years. The government, in this case the federal government has
been colluding with the managed care industry to marginalize the
expertise of professionals and to continue to disproportionately ration care to
anyone with a mental illness or an addiction. The managed care industry and
federal and state governments can spin that anyway that they want, but they
can't get rid of the dismal record of the past 20 years or the fact that the government is now obviously promoting it.
Monday, July 9, 2012
More PPACA News
More news on the Affordable Care Act (ACA) in the New York Times today. I certainly want to applaud the New York Times for including another article that is fairly positive in terms of content regarding psychiatry and mental illness. On the other hand it is probably not a realistic appraisal of the impact the ACA will have on increasing the quality and availability of mental health services in the United States.
As I posted a couple of days ago the predominant business paradigm in healthcare is the main obstacle to reform, not the laws regulating healthcare or the payment mechanism. As long as the health care system is run by people who have no expertise and are making essentially business decisions we can expect the ongoing triple whammy of more health care inflation, poorer healthcare quality, and a lack of innovation.
This opinion piece is interesting because it includes a comment about what was supposed to be the great leveler of the healthcare landscape - the Mental Health Parity and Addiction Equity Act of 2008. Similar opinion pieces were written about this law as soon as it came out in 2008. It was a cause for celebration among psychiatrists and advocacy groups. And then slowly over time it became clear that reality did not match the enthusiasm, even by a long shot.
The same process is occurring as I write this about the ACA. Through a process of being favored by politicians and regulation, managed care companies have always been able to use purely subjective guidelines often under the rubric of "medical necessity" to deny care to people with mental illness or addictions. There is absolutely no reason to expect that will not continue to happen.
Let me be clear about the types of problems I am referring to. I am referring to people with significant disability due to major mood disorders, psychotic disorders, and addictions who have life-threatening problems and no real access to solutions other than spending a few days in a hospital ward that is poorly equipped to help them and the hope that they can make it to a 10 or 15 minute equally meaningless outpatient appointment anywhere from one to four weeks down the road. These people frequently have associated medical problems and no resources like a stable income or housing.
The proponents of the ACA will tell you that these people will now be seen in integrated outpatient primary care clinics and the quality of their care will improve. The logical question is why have the resources to help them been denied for the past 20 years and what is the likelihood that dynamic will change with an additional 15 to 20 million people in the system?
Psychiatric illness on a par with all other medical disorders? I don't think so. Not as long as a faceless managed care bureaucrat with no accountability can throw you out on the street, deny a medication that you need for an "equivalent" medication, or tell you that the treatment for your problem involves an endless series of "medication checks" with a "prescriber".
George Dawson, MD, DFAPA
Richard Friedman. Good News for Mental Illness in Health Care Law. New York Times July 9, 2012.
As I posted a couple of days ago the predominant business paradigm in healthcare is the main obstacle to reform, not the laws regulating healthcare or the payment mechanism. As long as the health care system is run by people who have no expertise and are making essentially business decisions we can expect the ongoing triple whammy of more health care inflation, poorer healthcare quality, and a lack of innovation.
This opinion piece is interesting because it includes a comment about what was supposed to be the great leveler of the healthcare landscape - the Mental Health Parity and Addiction Equity Act of 2008. Similar opinion pieces were written about this law as soon as it came out in 2008. It was a cause for celebration among psychiatrists and advocacy groups. And then slowly over time it became clear that reality did not match the enthusiasm, even by a long shot.
The same process is occurring as I write this about the ACA. Through a process of being favored by politicians and regulation, managed care companies have always been able to use purely subjective guidelines often under the rubric of "medical necessity" to deny care to people with mental illness or addictions. There is absolutely no reason to expect that will not continue to happen.
Let me be clear about the types of problems I am referring to. I am referring to people with significant disability due to major mood disorders, psychotic disorders, and addictions who have life-threatening problems and no real access to solutions other than spending a few days in a hospital ward that is poorly equipped to help them and the hope that they can make it to a 10 or 15 minute equally meaningless outpatient appointment anywhere from one to four weeks down the road. These people frequently have associated medical problems and no resources like a stable income or housing.
The proponents of the ACA will tell you that these people will now be seen in integrated outpatient primary care clinics and the quality of their care will improve. The logical question is why have the resources to help them been denied for the past 20 years and what is the likelihood that dynamic will change with an additional 15 to 20 million people in the system?
Psychiatric illness on a par with all other medical disorders? I don't think so. Not as long as a faceless managed care bureaucrat with no accountability can throw you out on the street, deny a medication that you need for an "equivalent" medication, or tell you that the treatment for your problem involves an endless series of "medication checks" with a "prescriber".
George Dawson, MD, DFAPA
Richard Friedman. Good News for Mental Illness in Health Care Law. New York Times July 9, 2012.
Thursday, July 5, 2012
SCOTUS decision irrelevant for health care reform
The decision by the Supreme Court on June 28 regarding the Patient Protection and Affordable Care Act has generated a lot of speculation about the implications for health care reform, the politics of the Supreme Court, the health of Supreme Court justices, and the impact on two party politics. Very few people seem really focused on the issue of health care reform. Even the most positive spin on this decision misses the mark. This article by Brooks that seems to center on the ideology of the Court and how the decision is healing is illustrative with the following quote:
"People in both camps seem to agree: We’ve had a big argument about health care over the past several years, yet we haven’t tackled the big issues. We haven’t tackled the end-of-life issues. We haven’t fixed the medical malpractice system. We are only beginning to correct the antiquated administrative systems."
"People in both camps seem to agree: We’ve had a big argument about health care over the past several years, yet we haven’t tackled the big issues. We haven’t tackled the end-of-life issues. We haven’t fixed the medical malpractice system. We are only beginning to correct the antiquated administrative systems."
And:
"... we haven’t addressed the structural perversities that are driving the health care system to bankruptcy. ... American health care is still distorted by the fee-for-service system that rewards quantity over quality and creates a gigantic incentive for inefficiency and waste."
The observations like essentially all observations about the ACA ignore the basic fact that this IS managed care and in fact - managed care on steroids. Managed care has proven time and time again to not contain costs and introduce administrative inefficiency in over two decades of experience. Whether or not the Supreme Court allows it to go forward or it is politically defeated in the future is peripheral to the fact that managed care has not worked as a device to contain health care inflation and it certainly does not provide either quality care or innovation. It can make money for stockholders and CEOs. In fact, in an up or down economy I can't think of a better recipe for making money than being able to deny health care benefits to a group of health care plan subscribers or deny or reduce reimbursement to physicians.
The structural perversity in the system is that in the overwhelming number of cases, personal health care decisions are no longer made between a patient and a physician. Contrary to managed care hype, their decisions are not necessarily based on any legitimate evidence. They are based on what is good for business and in this case we don't have a business that needs to build a better product. We have a business that has to ration access to a service.
Until that is recognized - health care reform is basically continuously rearranging ways to shift money from the people providing the care and the people paying for care to business entities that are "managing" the care.
The outcome is as predictable as where the managed care systems have gotten us to at this point.
George Dawson, MD, DFAPA
"... we haven’t addressed the structural perversities that are driving the health care system to bankruptcy. ... American health care is still distorted by the fee-for-service system that rewards quantity over quality and creates a gigantic incentive for inefficiency and waste."
The observations like essentially all observations about the ACA ignore the basic fact that this IS managed care and in fact - managed care on steroids. Managed care has proven time and time again to not contain costs and introduce administrative inefficiency in over two decades of experience. Whether or not the Supreme Court allows it to go forward or it is politically defeated in the future is peripheral to the fact that managed care has not worked as a device to contain health care inflation and it certainly does not provide either quality care or innovation. It can make money for stockholders and CEOs. In fact, in an up or down economy I can't think of a better recipe for making money than being able to deny health care benefits to a group of health care plan subscribers or deny or reduce reimbursement to physicians.
The structural perversity in the system is that in the overwhelming number of cases, personal health care decisions are no longer made between a patient and a physician. Contrary to managed care hype, their decisions are not necessarily based on any legitimate evidence. They are based on what is good for business and in this case we don't have a business that needs to build a better product. We have a business that has to ration access to a service.
Until that is recognized - health care reform is basically continuously rearranging ways to shift money from the people providing the care and the people paying for care to business entities that are "managing" the care.
The outcome is as predictable as where the managed care systems have gotten us to at this point.
George Dawson, MD, DFAPA
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