The New York Times - Steers Mental Health Conversation In the Wrong Direction

An editorial came out today in the New York Times entitled The Crazy Talk About Bringing Back Asylums.  They took a line from President Trump that the Parkland shootings could have prevented if there were more psychiatric beds.  I am  sure was intended to temper any anti-gun sentiment rather than suggest the need for reform of mental health services, but the editorial suggests that this triggered a new debate about the need for asylum beds and looks at (on the negative side) a caricatured extreme view of increased bed capacity.  This political approach to mental health care is exactly what is wrong with policy for the past three decades.

The first mistake in the article is the following sentence:

"Psychiatric facilities are unlikely to prevent crimes similar to the Parkland shooting because people are typically not committed until after a serious incident."

Any acute care psychiatrist can attest to the fact that this is incorrect.  A considerable amount of mayhem, violence and aggression is prevented by the availability of both acute care inpatient beds and psychiatrists treating potentially aggressive people in both inpatient and outpatient settings.  There are no controlled studies of the problem because they would be unethical.  You can't randomly assign homicidal or suicidal people to placebo treatments.  They all have to be actively treated.  At times courts release people who have threatened suicide, violence or homicide without treatment for the associated mental illness and they go on to complete exactly what they said they were going to do.  At other times patients will say that they are very satisfied that they were treated because they recognized they were irrational and about to commit an irreversible act.  The clearest example is the person who is aggressive form the time of admission and the aggression does not abate until they have been actively treated for several days.  People are committed on the basis of all of these scenarios and before serious incidents occur.

Instead of Bring back the asylums they thought they would attempt other slogans to "steer the conversation" presumably about improving the care of mental illnesses in the United States.

1. Demand sensible commitment standards:  

There are essentially just three commitment standards:  dangerousness to self (or suicide potential), dangerousness to others (or aggression and in some cases homicide potential), and grave disability (or an inability to care for oneself).  What could be more sensible?  The problem is that the law is subjective and there is always a way around sensibility.  That workaround could involve a highly aggressive defense attorney with a goal to get the patient "off" rather than worry about any consequences. It could involve a number of administrative issues like the cost of civil commitment (obviously cheaper to not try) or an arbitrary decision by a hospital or court administrator that there are just "too many commitments" and it is time to roll them back- at least until the next adverse outcome.  Another common way around commitment is just to ignore the grave disability standard and in effect say commitment will occur only for dangerousness. If someone really wants to split hairs - the dangerousness has to be "imminent" and it can always be not imminent enough.  For commitment standards to have any meaning at all - they have to be implemented by sensible people.  We need to demand sensible people. More importantly there needs to be accountability and available data from commitment courts on outcomes.

The other part of the problem is that psychiatric beds are so rationed that in order to get into one - managed care organizations say that you need to be dangerous in order to get admitted.  That creates a false burden on court systems who may not be sensible about commitment in the first place.  In the context of this demand they are even less sensible.     

2.  Create a continuum of care:

The NYTimes takes a historical approach going back to the Kennedy era and the deinstitutionalization argument.  First of all there are places that have a continuum of care. The community psychiatry movement was highly successful in following people outside of state hospitals and supporting them in independent living.  Some cities like Madison, WI have a large community mental health center as well as several assertive community treatment (ACT) teams that follow people with serious mental illnesses.

The reason why there is no followup similar to medical and surgical patients with significant disabilities is several fold.  Rationing by the insurance industry and federal and state governments is the primary cause.  It is easy to save money by denying equivalent care to the mentally ill and people with severe addictions.  Over time this has led to separate acute care services in some community hospitals and long term care facilities that are typically run by the state. The large majority of hospitals in most states do not provide acute psychiatric care.  Both acute care and state systems are rationed to provide as little care as possible. It is currently in the financial interest of every managed care and insurance company in the country to maintain this fragmented system of care because it saves them all money.  In the meantime disproportionate amounts of money and resources are funneled to very other type of specialty care.

At the state level, the bed situation is so dire or nonexistent in state hospitals that it should be very clear that they have adopted the managed care rationing plan to eliminate care for the mentally ill.  That is the reason that jails are the defacto psychiatric hospitals at this time.  There is of course no standard for psychiatric care in jails and most people tell me they do not get their prescribed medications.  This is also the reason why asylum care does not work.  Asylums were basically buildings that were poorly managed by the state.

3. Stand up for insurance parity:  

Parity is a joke.  Insurance industry rationing and micromanagement of mental health treatment has continued unabated since the passage of the  Mental Health Parity and Addiction Equity Act.  After watching professional organizations and  mental health advocacy organizations patting themselves on the back after this legislation was passed - it has been more than a little depressing for psychiatrists on the front lines to watch as the denials of care are unchanged from before the bill.  Those organizations have been standing up for parity and against stigma for about 20 years with no results.

It is difficult to get parity when most states have an insurance industry friendly complaint system and the physicians who want to complain are either employees of a managed care company or limited by confidentiality laws.  Standing up for parity is meaningless symbolism at this point. It doesn't require a complicated HHS investigation.  What is needed is a review panel in every state - staffed by psychiatrists who have no financial conflicts with the insurance companies being complained about.  The precedent for those review panels was the Peer Review Organization (PRO) panels that were set up to review all Medicare financed care in the 1980s and 1990s. There is no reason why those reviews should occur today.  The only really effective alternative has been an activist attorney general ordering some of these companies to correct egregious denials of care.  Activist attorney generals do not occur frequently enough to make a sustained difference.

The larger problem is the way that healthcare is funded in the USA. I will add an illustrative post later in the week, but the percentage of the health care dollar dedicated to the treatment of mental illness is at an all time low.  The Hay Report of the 1990s documented the disproportionate drop in health care funding and it seems that governments and insurance companies expect it to stay at that level.

The NYTimes says that all it will take is a "collective will and a decency to act".  Are they serious?  Isn't that all it will take to end mass shootings in public schools?  This is just another naive approach to public policy written by people with no expertise who are ignoring the political landscape.  It is fashionable to call those people stakeholders these days.

As usual the real stakeholders - people with mental illness, their families, and psychiatrists are left out.  The suggested slogans are as problematic as the one about bringing back asylums that the NYTimes was concerned about.


George Dawson, MD, DFAPA



Supplementary:

For detailed information about this problem go to the pinned Tweet at the top of this feed and all of the links.


References:

1.  The New York Times Editorial Board.  The Crazy Talk About Bringing Back Asylums.  New York Times June 2, 2018.


Graphics:

Kodachrome slide shot by me in 1982 of Milwaukee County Hospital.  Not an asylum but it looked like one.

           

       

A Return To Asylums Will Not Stop The Rationing

An article was published in the JAMA recently where three ethicists argue for the return of asylum care.  It has become an expected flash point for the antipsychiatry movement as well as some psychiatrists who still think that the word asylum has some meaning.  I thought I would add a more realistic opinion and solution.  I refer readers to the original article or many that I have written here about the reduction in bed capacity in long term psychiatric care.  The reductions are indisputable and well documented.  I am more interested in elucidating the mechanisms behind this reduction and the lack of effective care in the remaining community hospital beds.  The authors allude to the underlying dynamics as captured in the sentence "For the past 60 years or more, social, political, and economic forces coalesced to move severely mentally ill patients out of mental hospitals."  They discuss the well known euphemism for incarcerating psychiatric patients or "transinstitutionalization" and rotating the chronically mentally ill in and out of emergency departments.

The authors even go so far as pointing out the bloated estimated inpatient costs for care in Michigan at $260,000/year/patient and Washington, DC at $328,000/year/patient.   For comparison they include a state of the art facility the Worcester Recovery Center and Hospital that has 320 beds at a cost of $60 million per year or or $187,500/bed/year.  It is difficult to figure out why what may arguably be the best public hospital in the United States has the lowest cost of care for what may be more comprehensive services.  But that is part of the problem.  Most of these institutions are managed by human services agencies through the states and the real fiscal status is always difficult to ascertain.  State and business accounting frequently provides calculations for bed or per patient rates that seem to include unrealistic estimates of overhead costs (often for subpar facilities).  The administration of many of these facilities also seems to depend on restricting psychiatric care at several levels.  In many cases the managed care concept of "medication management" or a "med check" mentality is applied, often with the overall plan of replacing psychiatrists with "prescribers".  Any notion of quality is trumped by a managed care notion of "cost-effectiveness" that typically includes removing psychiatrists from management positions and delegating policy and management at the institutional level to people with no training in psychiatry.

The authors accurately describe the problems of severe mental illnesses.  People have very complex neuropsychiatric disorders and will either not be getting well soon or will never recover enough functioning to do well in any community setting.  They were some of the first victims of "medical necessity" criteria.  I was a Peer Review Organization (PRO) reviewer for Medicare hospitalizations in the states of Minnesota and Wisconsin in the 1980s and 1990s.  For at least part of that time I was sent boxes of medical records from state hospitals for review.  If I looked the the records and decided the patient should continue to be hospitalized, I would get a call from the Medical Director of the PRO suggesting that I should consider the medical necessity criteria.  In the case of long term care, that meant that the patient was "stable" meaning that I would not expect them to change significantly with additional treatment.  If I could say that, the hospital was notified that the patient did not meet criteria for continued long term hospitalization and they needed to be discharged.  In fact, it was very likely that although they were not changing at a rapid enough pace, they would still present formidable problems for community placement.  It may be impossible to discharge them.  In many cases discharge resulted in almost immediate readmission to an acute care hospital and the cycle emergency department to brief hospital admission to homelessness to jail or readmission occurred.  At least until the person was sent back to the state hospital.

In her opinion piece, Dr. Montross suggests that these patients have been abandoned in the name of autonomy or  treating people in the so-called "least restrictive alternative."  That seems at odds with frequent sustained incarcerations for minor and in some cases trivial offenses.  What is really going on here and why do people continue to ignore it?  I have analyzed the problem many times and it is apparently so institutionalized at this point that nobody sees it as a problem anymore. The problem that I continue to point it out is managed care and all of the rationing mechanisms that they employ.  The very first one in the paragraph above is the so-called medical necessity criteria.  Any managed care company physician reviewer can deny care based on their own proprietary guidelines or a purely arbitrary and subjective interpretations of those guidelines.  Managed care companies can harass physicians with mountains of unnecessary paperwork and deny payment or demand payment back based on more subjective interpretations.  Even more problematic, states have incorporated some of these same management techniques and almost uniformly have completely abandoned quality in favor of "cost-effective" care which is quite frankly - care on the cheap.

The end result of all of this cost cutting, rationing, and insurance company profiteering at the expense of patients with mental illness or substance use problems is extremely poor quality care.  One of the authors suggests longer inpatient treatment may be the solution.  Right now practically every psychiatric hospital does their best to get patients discharged in 5 days or less.  Outpatient psychiatrists see patients who have not been stabilized after a 5 day admission.  That is business as usual in acute care psychiatric hospitals.  If that discharged patient makes it to an out patient clinic, they are seen for 10 - 15 minutes in a medication management visit (another fabrication of the managed care industry and the US government) and if they are lucky they discuss the medication and whether it is effective for symptoms or causing side effects.  The problem is that there are important areas in the patients life - like their cognition and social behavior, that are never discussed or evaluated in any productive way.  Very few patients with severe mental disorders receive any kind of psychotherapy despite the evidence it is useful to them.

Putting all of these problems back into the asylum will have predictable results.  The medication management mentality is basically now inside the walls of an institution. There is no enlightened, research driven treatment that addresses all of the problems that the person has.  The asylum is typically administered by a bureaucrat, bound by the same arbitrary budgeting that comes down from the Governor's office.  Across the board spending cuts by a certain percentage and no adjustments when the cash flow is positive.  Money "saved" on asylum care transferred to the state's general fund and used to build roads or whatever was stated in campaign promises.  Suddenly the asylum is an overcrowded bottleneck due to cost shifting by every county in the state who does not want provide services for serious mental illnesses.

The alternative?  How about doing things the right way for once.  We seem to have people who recognize that mental illnesses are not going away, that the current care is atrocious and inhumane, and that it is time to do something about it.  Estimates for the number of people in each state with severe mental illnesses are out there.  Consistent reasonable funding is necessary.  That includes the state, but also it is time to not allow managed care companies to dodge these costs and transfer them to the tax payers.  Finally, it it time to eliminate stakeholder meetings and develop systems of care for the people who it matters the most to - patients, families, psychiatrists, and the other mental health and medical professionals involved in providing this level of care.

Without those conversations, an asylum is just a poorly managed building.    




George Dawson, MD, DFAPA



References:

1: Sisti DA, Segal AG, Emanuel EJ. Improving long-term psychiatric care: bringback the asylum. JAMA. 2015 Jan 20;313(3):243-4. doi: 10.1001/jama.2014.16088.  PubMed PMID: 25602990.

2:  Christine Montross.  The Modern Asylum.  New York Times February 18, 2015.