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





         

Accountability - The Last Refuge of a Scoundrel

On April 7, 1775, Samuel Johnson said:  "Patriotism is the last refuge of a scoundrel."  His biographer had to clarify that Dr. Johnson was not talking about love of country but "pretend patriotism which so many have made a cloak for self interest".  We see the rhetorical application in American elections where politicians spend more time on discussions of their military records rather than issues relevant to any kind of plan that they have for the nation or solving any real problems.  Nunberg makes the observation that that the term can also mean an irrational bias favoring one's country and that Americans have applied the term indiscriminately at times. He also points out that it can be a word designed to put people on the defensive.  

If I had to pick a word in the medical field that has similar uses - it would be "accountability".  There has probably been no single word more responsible for facilitating managed care and recent government intrusions into the practice of medicine.  If you think about the premise of physicians being "accountable" to politicians and businesses - it is absurd on the face of it.  Taking a professional who has been trained to be accountable to an individual patient and who operates in a professional environment that specifies behavior toward that person and telling them that they are now going to be monitored by businesses with a goal of maximizing profits or politicians with numerous conflicts of interest and a clear interest in getting re-elected - is an ongoing disaster.  So  how has it happened?  I would suggest that most of it has to do with rhetoric.

Before I point out the medical applications of the accountability rhetoric let me say that I don't consider this to be specifically applied to medicine.  Accountability rhetoric is broadly applied by any person or group seeking some kind of political advantage.  An obvious example is education and teaching.  Politicians everywhere get a lot of mileage out of the idea that they are going to hold teachers accountable usually through standardized test scores.  It has become a pat answer to taxpayers concerns about the money being spent on education and low graduation rates.  In some states, the test scores are marched out every year and used to rank schools and teachers.  Never mind the fact that the school system that produces the top international performance scores does not work that way.  In Finland, a professional teaching culture is by far and away the most significant factor in their academic excellence.  In the book written about this the teachers say they would not tolerate the kinds of intrusions that are common in the United States.  These intrusions are all based on accountability rhetoric.  

In preparing for this post, I searched my e-mails from the past three years and found 1800 e-mails containing the word accountability.  Most of those hits were due to the Health Insurance Portability and Accountability Act (HIPAA).  If you read the long title of this act it was clearly doomed out of the box.  The major impetus for the PPACA (Obamacare) was health insurance portability suggesting that HIPPA was already a failure.  That did not deter legislators from including a Privacy Rule under HIPAA to supposedly crack down on privacy violations.  My read of the bill is that is actually broadens the use of anyone's medical information among all "covered entities" affiliated with your health plan.  In the meantime,  the Privacy Rule was so threatening that it almost immediately made it more difficult for the doctors doing the work to get access to data.  Was it necessary for physicians?  Absolutely not - physicians are trained in medical privacy and all broad breaches of medical privacy have been due to either hacking or business people losing computers with significant amounts of data.  Make no mistake about it - politicians will be there to make the most accountable people accountable and greatly decrease their efficiency.   A great example of the title of this post.

I have recently posted a number of examples of accountability rhetoric being used for political leverage against physicians.   It can be used by medical boards, advocacy organizations, state agencies, federal agencies, and specialty boards in addition to politicians.  I am going to focus on a single example and that is Medicare.  All of the information that follows is public and can be accessed through the Medicare link on the American Psychiatric Association's web site.  I picked it up on my Facebook feed but it disappeared and I had to call APA staff to figure out where it went.  I am very familiar with the history of Medicare quality initiatives because I was one of their quality reviewers for inpatient hospitalizations in Minnesota and Wisconsin in the late 1980s and 1990s.  If you look for inpatient psychiatry measures you will find that many of them (polypharmacy, multiple drugs from the same class, discharge planning) are unchanged from that era, despite the fact that the review organization was disbanded because it did not find enough quality or utilization problems to justify its ongoing existence.

The APA points out that Medicare now has a fee scale that takes into account "quality of care measures instead of just paying a standard fee for every procedure (CPT) code".  They have a Physician Quality Reporting System (PQRS) that requires psychiatrists to report on one measure in order to avoid a 1.5% penalty.  For 2013 that report has to be made on one Medicare patient.  This is described as an "incentive" to report on quality performance measures and of course a "penalty" for those who fail to report.   A managed care company would call it a "holdback" in that it is technically work that has been done, but the no cost way to turn it into an "incentive" is just to take it from the people doing the work and make it seem like they are rewarded with it later.

The document goes on to document "measures identified as pertinent to psychiatrists (along with their designated codes)".  If you are a psychiatrist read through these reporting measures and marvel at the morass of initial codes that I am sure are going to grow as this administrative nightmare continues.  The further problem is that Medicare/CMS clearly has the goal of comparing physicians and holding them accountable based on the fantasy that these measures actually mean something in clinical practice or even the world.  And if this list of measures is not enough, there are also 50+ page guidelines online like: "The American Medical Association-convened Physician Consortium for Performance Improvement - Adult Major Depressive Disorder Performance Measurement Set" that describes an additional set of performance measures.  The AMA is involved and if you click the link 2013 PQRS Quality Measures you can search on Major Depressive Disorder and find the following links.  You can download the 50+ page document from the top link.

Most people realize that physicians currently have some of the highest burnout rates of any group of professionals.  Those burnout rates are directly related to micromanagement even before we get to the level I just described in the above paragraphs.  The paradox that every physician is aware of is that these reportable measures are not valid objective markers and they are being promoted by bureaucrats who not only have no accountability but in the case of the mental health system of care are some of the same people who destroyed it in the first place.  Don't forget that Congress skewed insurance coverage of mental illness and addictions so badly that Senators Wellstone and Domenici had to write legislation in an attempt to correct that.  At this time the final form of their legislation is still pending.

So accountability has become the last refuge of scoundrels.  Be very skeptical of any politician or bureaucrat waving that flag.  It has little to do with reality and more to do with promoting their own self interests while creating a tremendous and unnecessary burden for the doctors they regulate.

George Dawson, MD, DFAPA

Nunberg G.  Going Nucular: language, politics, and culture in confrontational times.  Cambridge: MA Perseus Books Group, 2004.

For a complete analysis of political doublespeak as applied to medicine see:

Robert W. Geist:  Hot Air Index: Political/Commercial Double-speak Lexicon for Medicine