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





         

Question For APA Candidates? OK Here It Is.

"Why are there no leaders with vision in the APA who can focus us on the best science and the best psychiatry to provide treatment for individual patients with severe mental illnesses?"


I got a message today that I should craft a question for the American Psychiatric Association (APA) candidates.  It is election season and the LinkedIn forum is apparently the place for political debate.  I can recall asking a question last year along with James Amos, MD (The Practical Psychosomaticist).  The questions had to do with Maintenance of Certification (MOC) and the arduous recertification schedule that was essentially invented by the American Board of Medical Specialties.  Dr. Amos has done more to maintain this issue at a high level of visibility than any other psychiatrist.  That includes looking at the paucity of evidence that it is superior to life-long learning and CME as we all know it.  I  went to LinkedIn to look for my post from a year ago and it wasn't there.  The earliest post is from April 29, 2013.  This is a forum that was suggested to replace the long running member-to-member (M2M) listserv managed by the APA.  It was in M2M that members learned their concern about the MOC issue would be ignored despite overwhelming support on the basis that only 25% of the members voted and a 40% vote was required to pass the measure (see supplementary info below).

The events associated with that vote continue to bother members greatly.   It is seen as a continuing symptom that APA membership does not translate into any support for front line psychiatrists.  We have witnessed decades of increasing rationing and onerous regulations that have been basically brushed off at the level of the APA.  There has been minimal activity in responding to politicians, regulators, and businessmen.  It seems that whatever these special interests want to do - the APA is willing.  We had a billing and coding debacle in the 1990s with the rest of medicine.  Instead of pointing out that this was a purely subjective scheme designed to allow the persecution of any physician, the stance of both the APA and the AMA was "we will give you what you need to be better billers and coders."  We have had three decades of managed care utilization review, prior authorization, and pharmacy benefit managers and the response from the APA has been literature on how to be a better managed care psychiatrist.   There was a lawsuit against some managed care payers for a lack of parity but I don't think there is any evidence that the members who were forced to provide free care have gotten much benefit from that.

The most telling event about where the APA and AMA are at is their full scale cooperation with the PPACA (aka Obamacare) and so-called collaborative care.  In many if not most of those models of care, a psychiatrist collaborates with primary care physicians in treating depression or anxiety in their clinics.  In many of the models, the diagnosis hinges on a rating scale determination of depression or anxiety.  The rating scale score is the diagnosis.  The treatment modality is a medication - usually an antidepressant.  In some models the psychiatric consultant never sees the patient.  I just realized it, but this is all eerily similar to managed care reviewers several states away telling attending psychiatrists how to manage their patients.  This is managed care - a business centered model of providing medical care.  A model that many (myself included) do not consider a valid method of providing medical care.  And yet, the President of the APA and several other psychiatrists promote this as a model of care.  What physician would do 4 years of residency training to sit in an office, look at rating scale scores, and recommend antidepressant doses?  Why would you train all of those years and know all of that theory for such a simple task?

That simplistic collaborative care model captures the primary problem in psychiatric leadership today.  Here we stand at a crossroads.  We are studying the most complex organ in the body and we clearly know more about it now than at any point in the past.  The literature in brain science as it applies to psychiatry is growing exponentially.  We have some of the best thinkers in the world in all areas of the field ranging from pure neurobiology to psychopharmacology to imaging to neuropsychiatry to medical psychiatry to community psychiatry to psychotherapy.  There is so much to learn about the brain and psychiatry and what are we doing with it at a global level?

Nothing as far as I can tell.  The leadership of the APA is locked into a mindset from the Clinton administration.  The APA is acting like we have a responsibility as a profession to address bloated mental health statistics and provide population-based psychiatric care to the masses.   We have a responsibility to provide cost-effective care to the masses.  We have a responsibility to fight stigma wherever we find it because this is the real reason why people, governments, and insurance companies discriminate against psychiatrists and their patients.  We have to grin and bear it when some clown attacks the profession despite the fact that thousands of our colleagues go to work everyday and many toil with inadequate resources, impossible conditions, a lack of cooperation and they still get the job done.  Thrown into the breech with no support, front line psychiatrists are still getting the job done.

The APA on the other hand has done very little to support that effort.  APA officials seemed to breathe a sigh of relief about the vote on the MOC issue.  I heard one of them speak about it at a local meeting.  She told us all about how the new certification fees were really not a windfall for the American Board of Psychiatry and Neurology (ABPN).  This was really an expensive process after all.  I finally learned that this was really an initiative by the ABMS and that participating boards did not really have a choice.  If most of the boards voted for recertification all of the boards had to participate even if they voted against it.  I had learned about 10 years ago that the American Board of Obstetrics and Gynecology ( ABO+G) had a robust program that consisted of didactic material every year that was designed to bring all members up to speed.  A test was taken every year on that well defined information.  At the time there was no MOC and to me it seemed like an ideal program to assure that all members of a particular specialty were up to date and studying relevant information about what was important for the specialty.  For a while, I promoted this model as the preferred model for ongoing professional learning.    The APA does provide a similar program called Focus that could naturally fill the same role.  Typical MOC exams are not on a focal body of material and the pass rates are high.  Candidates of all specialities typically take time off of work (an off of vacation) to study for these examinations in addition to paying high examination fees for a test that is designed for the test makers and not the test takers.  A test of random facts for the purpose of recertification is not the same thing as a test for professionals to assure they are all up to the same standard.

The APA has just completed a much criticized multi-year effort of revising the DSM and producing the DSM-5.  I think that has been a good effort and with the associated online material it is a definite advance relative to previous editions.  That does not mean I am in agreement with everything in the book, or think that all of the diagnoses in that text exist.  I do think that it covers all of the major diagnoses and severe mental illnesses that psychiatrists treat.  On an academic and clinical level the APA needs to do much more.  Hospitals and clinics currently are being run by administrators with mixed agendas.  We are seeing business people conduct psychiatric care.  The APA used to provide comprehensive guidelines for the treatment of aggression in inpatient settings.  It used to have timely treatment guidelines describing the role of psychiatry and what the standards of care are.  By abdicating that role, we now have business organizations and nonprofessionals dictating care for people with severe mental illnesses.  We have psychiatrists who have to defend their care against those nonprofessional guidelines every day.   That is hardly the expected behavior of a professional organization.

Any psychiatrist should be concerned about the fact that their professional organization does not seem to support the members doing the work of psychiatry.  Any psychiatrist should be concerned that the APA does not vigorously defend the profession and that it seems to have adapted the pseudoscientific methods of governments and managed care organizations.  Any psychiatrist should be concerned that the APA has adopted the questionably valid ABMS preparatory school model of professional education that is unfocused and a waste of time and money.  Any psychiatrist should be concerned about the fact that we have some of the greatest minds in American medicine in our medical institutions and our professional organization is lurching back to the Clinton administration of the early 1990s.  Back to the time when a few political insiders thought that managed care was a good idea.  All of these things considered the question I will post to the candidates is:  

"Why are there no leaders with vision in the APA who can focus us on the best science and the best psychiatry to provide treatment for individual patients with severe mental illnesses?"
 
That is how I was trained and how every psychiatrist I know was trained.  It is time our professional organization consistently gives us what we really need.


George Dawson, MD, DFAPA



Supplementary 1:  This was the APA 2011 election report I got on the following referendum to basically eliminate patient feedback and maintain a cognitive exam very 10 years.  Although the APA maintains that it requires a vote of 40% of the voting members, the vote to support these measures exceeded the votes for the President Elect and the Secretary (both national candidates) by 1373 and 1388 votes respectively. (Reported February 18, 2011)

The APA was petitioned by members to hold a referendum on the issue of informing the ABPN as follows regarding its proposed maintenance of certification requirements.

1) The patient feedback requirements for the purpose of reporting to the Board is unacceptable, as it creates ethical conflicts, and has the potential to damage treatment.

2) The requirements other than a  cognitive knowledge examination once in 10 years, regular participation in continuing medical education, and maintenance of licensure, pose undue and unnecessary burden on psychiatrists.

Member Referendum	Support	5,525 (80%)
	Do not support	1,418 (20%)

The referendum did not pass. APA received ballots from 25% of the voting members.

The APA Operation Manual states the following regarding member referendums: “The adoption of a referendum shall require (a) valid ballot from at least 40 percent of the voting members, (b) the affirmative vote of at least one-third of all the voting members of the Association, and (c) the affirmative vote of a majority of those members who return a valid ballot.

Supplementary 2:  Another one of the sorry miscalculations made by the APA and its officers is the image it projects to potential trainees.  Applying the dynamic I point out in this post, any potential resident ends up asking themselves:  "Why would I want to join a speciality that seems to want its members to have less expertise than they used to rather than more?  What other speciality does that?"  I tried to address that as a response to a current resident written on his blog and for some reason the response was never posted.  You can read his original post here and my response below:


The most significant reasons why psychiatry has the image problem that you discuss is that the profession is politically inept and our largest professional organization is not addressing the problems that psychiatrists face on a day-to-day basis on the front lines. The biggest front line problem is that practically all systems where psychiatrists work have mercilessly slashed resources for treating the mentally ill. We also seem to attract a number of ideas from critics that are not helpful. The example you posted about a prescriber with watered down qualifications is a case in point. In what other specialty does anyone suggest that the practitioners of the future should be less qualified?

That type of nonsense only happens in psychiatry and it is completely inconsistent with current research. In this weeks’s Neuron there is a perspective on Computational Neuropsychiatry. As neuroscience becomes more relevant to daily practice psychiatrists need that level of training in addition to medical and psychotherapy skills. We seem to have a lack of visionaries right now who can put all of that together.

I would encourage psychiatrists of the future to be thinking more along these lines, than the rationed managed care model of care that is currently being promoted. It turns out that “cost-effective” psychiatric care is frequently the same as no care at all.

GD

Buy This Book

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

Happy Labor Day II - To All of the Docs on the Assembly Line

Last year I posted a Labor Day greeting to all of the docs laboring in American medicine.  I used the assembly line metaphor for obvious reasons - physicians were no longer being treated like knowledge workers but were being treated like assembly line workers.  Circumscribed patient visits were the widgets.  In the case of proceduralists the procedure was the widget.  One of my friends referred to himself as a "scope monkey" based on the expectation for the number of procedures he was supposed to produce every year.  Have there been any substantial changes in the last year?

The bad news is that there have not been. Managed care continues to consolidate its monopoly.  The final product under the Affordable Care Act (PPACA) will result in unprecedented leverage on the part of that industry over physicians and patients.  I often compare the healthcare industry to the financial services industry when it comes to an example of government determined monopolies.  The 401K is a great example of how this works.  The 401K was sold to the American public as a great way to save for retirement.  When the choices in 401K were limited it was sold as a way to simplify the 401K for most people.  The truth about 401Ks is that they have not been a very successful investment vehicle.  They put trillions of dollars of retiree savings at risk and the fees they charge are even more outrageous than medical fees.  I just looked at a bond fund prospectus this morning that shows on an investment of $10,000 I could expect to pay $1,000 in fees every 10 years.  Considering that there are about $9 trillion dollars in 401Ks and IRAs that generates about a trillion dollars in fees (about $90 billion a year) for the financial services industry.  Those fees are generated independent of the general goal of retirement funds - actually having money for retirement.  My prospectus has the usual disclaimer: "The value of your investment in the fund can go up or down.  You can lose money by investing money in the fund."  As many baby boomers found out that can be 30-40% of your principal.

How does managed care compare?  The most interesting game has been the idea that all fees will increase substantially with the implementation of the PPACA.  This bill allows for unprecedented merger and efficiencies.  It allows for only 80% of the health care premium to be devoted to the actual provision of health care services.  It is logical to assume that a greater percentage of the health care dollar devoted to health care would also decrease premiums.  There will be significant hidden savings associated with a model of care that is integrated and minimizes the amount of physician billing.  Insurance company rhetoric suggests that provided additional services to the uninsured with no limitations on pre-existing conditions will more than cancel out the monopoly advantages.  If that was true why lobby for large monopolies?

One of the indicators to me of just how much leverage the managed care industry has is the expected out of pocket costs for a retired couple on Medicare.   That number is currently $220,000 not including nursing home costs.  That is roughly more than four times the average retirement savings for most Americans.

The financial services industry and the medical industry are basically government mandated hidden taxes on the American people.  In exchange for that huge subsidy we get an industry that charges us significant fees to place our retirement funds at risk all of the time and another industry that rations health care and charges whatever they want in order to make money.  In the case of the medical industry the overriding philosophy is not consistent with an enlightened approach to employees that probably know a lot more about the provision of quality medical services than the administrators.

That conflict of interest is central to the deterioration of the practice environment and a diminished focus on quality care and a continued focus of the study and academic aspects of medicine.   Having medical care dictated by administrators using business guidelines or managed care reviewers using the same approach is demoralizing.  Unless this conflict of interest is adequately addressed - the focus of health care will be turning out widgets.  Only the widget producers will be valued.  Administrators making arbitrary decisions run the whole show.

All of this remains decidedly grim in terms of the practice environment where most physicians work.  It is only fair to consider some solutions.  I will try to avoid the political decisions I have advanced in APA and other medical forums over the past 20 years.  Physicians are uniquely oblivious to the fact that the science of medicine is routinely trumped by business and politics.  Are there any possible solutions?  For many years private practice was always considered an option.  With the PPACA that route will be more difficult because the solo practitioners and groups will probably be off the network and professionally isolated, but some will be able to practice in this environment.  There is still niche work where physicians can be paid professional salaries and still have adequate time to complete all of the administrative tasks and focus on quality work, but they are rare.

A single exciting model that I think can disrupt the usual managed care and government restrictions that I expect to flow from the PPACA comes from the University of Wisconsin and their Memory Clinics approach.  This is a statewide network of clinics focused on providing state-of-the-art and quality care across a number of settings.  Guidelines, continuing education, and consultation is provided from a University based department and there is a minimum requirement for for ongoing education every year.  I don't see why this model cannot be widely applied across psychiatry and all other medical specialties.  It brings the academic focus back into medicine instead of the current focus by governments and business.  The practice environment of medicine needs this academic focus and it would greatly enhance the practice environment and get us out of widget production.

That is my hope between this Labor Day and the next.

George Dawson, MD, DFAPA

More Talk on Psychiatry and the Affordable Care Act

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.

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

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:

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.

  

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

Conflict of interest and psychiatry - what's missing?

A new article looking at conflict of interest in psychiatry was presented on another blog to suggest that new rules are required to improve transparency. The article takes a look at six cases and the process used by Sen. Charles Grassley to publicize these cases. The article suggests that the reason for publicizing these cases was in order to support Grassley legislation (Physician Payment Sunshine Provision).  According to the article it was attached to the Patient Protection and Affordable Care Act and was never voted on alone. 

These cases were repeatedly publicized in the popular media and some of the problems with these cases and Grassley's analysis were never adequately discussed.  The clearest example is the case of Alan F. Schatzberg, MD of Stanford University. He was the chairman of the Department of psychiatry and when Grassley investigated the matter at the level of Stanford University and several pharmaceutical companies. You can read the exact details in this paper but the bottom line is that Stanford University has always maintained that it handled potential conflicts of interest in an appropriate manner consistent with their policies. They actually published a statement on their web page at the time.  He remained the department head and although he was apparently temporarily removed as the principal investigator on a federal grant but he was later reinstated. The authors of the article in this case suggest that exposing the conflict of interest had negligible effect on the outcomes in this case, but the fact is the case was handled according to university policy.

There are really two key elements in this paper that are critical. The first is why Grassley went after psychiatry in the first place. The article suggests this occurs because his aide Paul Thacker "Combed  the media for stories of influential physicians with industry ties. He then requested the physicians conflict of interest disclosures from their AMCs and compared them to payment schedules obtained from companies."  I had always wondered why physicians from other specialties were never mentioned or consultants from other departments. It is fairly well known that scientists and engineers can make substantial incomes to supplement their university salaries based on their expertise. So why was the "media combing" restricted to psychiatry?

If I had to speculate, I would suggest that media bias against psychiatry is a well known fact. It has actually been investigated and the frequency of negative press that psychiatry receives relative to other specialties is well known. (see paragraph 4)  The popular press has an automatic media bias against psychiatry and it should come as no surprise that prominent psychiatrists are investigated and reported more frequently than other specialists. This is why “combing the media” is really not a legitimate research method. It should be fairly obvious that prominent university affiliated physicians of all specialties have similar conflicts of interest and that the business stake in other specialties is probably significantly higher.

The second element that should be obvious to anyone skeptical of Congress is Grassley's quote in the article "The whole field of medicine is connected by a tangled web of drug company money. For the sake of transparency and accountability should the American public know who their doctor is taking money from?"  That sounds like there is an obvious answer in there somewhere but the U.S. Congress is the best case in point that transparency is essentially meaningless. There is probably no better example than Sen. Grassley himself.  You don't have to look too far to find campaign donations that align with the votes and the Senator's denial (see paragraph 8) that there is any connection.

These simple facts are left out of the Journal article and that represents a serious flaw to me. Is the U.S. Congress is a shining example of disclosure becoming a license to do whatever you want to do? If that is the case you really don't have the basis to suggest that transparency will allow the "power of sunlight to disinfect". It clearly does not have that effect in Congress.  That is at the minimum an appearance of a conflict of interest on par with any scenario described in this article.  When I point this out - the usual rebuttal is that doctors should have a higher standard when it comes to the appearance of conflict of interest.  Is that really true?  Should a doctor who already has a fiduciary responsibility to a patient and the patient's well being have a higher conflict of interest standard than one of the 100 most important law makers in the country?

The other issue here of course is that psychiatrists are conveniently thrown under the bus. Despite the qualifier in this paper is that "Nor did Grassley ever assert that psychiatry was more problematic than other specialties." (p 5).  You really don't have to make an assertion when psychiatry is apparently the only field you are investigating. That bias is totally consistent with one of the themes of this blog. 

When all else fails you can more easily scapegoat psychiatrists.  So why look for anybody else?

George Dawson, MD. DFAPA

Chimonas S, Stahl F, Rothman DJ. Exposing conflict of interest in psychiatry:
Does transparency matter? Int J Law Psychiatry.
2012 Oct 1. pii: S0160-2527(12)00072-6. doi: 10.1016/j.ijlp.2012.09.009.

[Epub ahead of print] PubMed PMID: 23036364.

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.

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.

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."

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