DOJ Sanctions America's Largest Psychiatric Hospital

The Department of Justice came out with a report this week on the way that psychiatric problems are being managed in the LA County Jail.  The conclusion was that prisoners were prevented in getting their constitutionally-required care for  mental illness and they cited deplorable environmental conditions, deficient care for inmates with obvious needs, inadequate supervision, and failure to provide adequate suicide prevention services.  There were 15 deaths by suicide in 30 months and the conclusion was that several of those deaths were preventable.  By previous agreement, the county had demonstrated compliance with suggested measures including the development of a robust electronic health record.  The resulting Memorandum of Agreement Between the United States and Los Angeles County, California Regarding Mental Health Services at the Los Angeles County Jail (MOA) is an interesting read and could be viewed as a blueprint for transferring psychiatric services from managed care hospitals to correctional facilities.  Unfortunately there is no obviously available detailed report on the findings at this time, but I have requested it through their web site.

The issue of psychiatric services being provided in county jails is a national scandal that hardly anyone seems to care about.  In terms of awareness it is probably well below the issue of mass shootings by people with mental illnesses.  Why is that important?  There are several issues that never seem to be mentioned in the press.  The first and foremost is how psychiatric services have been excised from clinics and hospitals by managed care companies - especially complex psychiatric issues.  Anyone who cannot be seen in a 15-20 minutes brief discussion about medications usually gets the message that they need to get services elsewhere.  Many people who end up in jail these days have chronic mental illnesses have been involved in minor violations (trespassing, disorderly conduct, drug possession/paraphernalia charges, etc) that are a product of mental illness.  Their stays are often complicated by a lack of available legal and financial resources that increase their stay times in jail.  The following table is based on data in Forbes magazine and corroborated by other sources describing the total populations in these facilities.


         County Jail by Size                                                Population

1.  LA County Jail	19,836
2.  Riker’s Island (New York City)	13,849
3.  Harris County Jail (Texas)	10,000
4.  Cook County Jail (Chicago)	9,900
5.  Maricopa County Jail (Arizona)	9,265
6.  Philadelphia, PA	8,811
7.  Miami Dade County Jail	7,050
8.  Dallas County (Texas)	6,385
9.  Orange County (California)	6,000
10.  Shelby County (Tennessee)	5,765

The epidemiology of mental illness in incarcerated populations varies by site, authors, and agencies involved but there is no dispute about it being significant.  In a 2005 survey by the Bureau of Justice Statistics, 64% of inmates reported a mental health problem.  Recent study of incarcerated women showed that 43% met lifetime criteria for severe mental illness and 33% met 12 month criteria.  Forty five percent of the women meeting 12 month criteria had severe impairment of functional capacity.  The authors of that study emphasized the need for assessment of mental health needs at the point of entry into the justice system in order to meet the complex needs of the patients.  The inherent problem is that the US justice system and American culture are set up to pay lip service to recognizing mental illness and diminished capacity and that has recently been complicated by essentially shutting down psychiatric services and offering jails as an alternative.

What are the basic problems here?  The first is a clash of paradigms - treatment versus punishment.  If a judge actually puts you in jail for trespassing when you are so confused you can't find your way off someone's property due to mental illness, substance use, or some combination that amounts to punishment for having a mental illness.  Some systems are more enlightened than others in dealing with that problem.  In some communities, the lack of psychiatric resources results in jail as an alternative to hospitalization or non-existent community services.  The hand off between corrections and medical systems of care is complex and it depends on a medical staff who know how to approach and treat patients from correctional systems.  It also depends on judges and prosecuting attorneys with resources to decide who can be adjudicated as unable to proceed and be diverted to treatment rather than trial.  Those resources need to include examiners who can see people in jail and make the necessary assessments about court versus jail.

The second problem is rationed services.  This is best illustrated not only by the collapse of the number of beds in community hospitals and the lengths of stay much shorter than comparable facilities in the European Union but by the underlying cause of all of these problems.  That cause was simply managed care.  Managed care has done an expert job of cost shifting by developing business friendly treatment criteria, abandoning the social and community mission of treating difficult problems associated with mental illness and addiction, and removing the element of humanism from psychiatric treatment.  When I first started to practice, discharging people from a hospital when a psychiatrist had serious concerns about whether or not they could make it or whether they would be safe was very uncommon.  Today those discharges are the rule rather than the exception largely due to the imaginary dangerousness criteria.  It frequently comes down to whether or not a person is "dangerous".  If they are not, they will find themselves whisked out the front door at their first request.  I have seen that happen when the patient could not find the front door.  The same dangerousness criteria allow for blocked admission from jails or law enforcement.

The third problem is the violent offender or criminal with mental illness.  The distinction is much less clear than most people think.  Psychiatrists Dorothy Ontnow Lewis and Harold Pincus published papers on the high prevalence of neurological abnormalities and histories of brain injury in death row inmates.  Many criminals start to use various substances early in their development and can develop psychiatric comorbidity s a result of this drug use.   In my experience treating criminals or more technically persons with antisocial personality disorder who develop mental illnesses as a result of their criminal lifestyle is a much different problem than a mentally ill person who runs afoul of the law due to their psychiatric symptoms.  The patient who is antisocial or a criminal first needs to be separated from patients without those characteristics to prevent exploitation of vulnerable patients.  Any psychiatric facility in a metropolitan area needs to have this type of capacity or it will diminish the ability of the inpatient service from caring for individuals who are violent and aggressive due to treatable psychiatric disorders.  These individuals are at high risk if they are cared for in correctional settings.

I hope that this post highlights the problem and the potential solutions.  I just read a piece in Nature this morning that highlighted the need to study suicidal behavior.  The Dutch psychiatrists who wrote it emphasize that research on suicide is underrepresented in the psychiatric literature relative to articles on schizophrenia.  In America today we currently have ten times as many mentally ill patients in jails than state hospitals.  We have mass shooting homicides and many of those aggressive individuals either had no resources for treatment or there was no identified path of care for those individuals.  We need an array of psychiatric services focused on violence prevention and treating people who have impaired functional capacity to the point that they run into problems with the law.  We need better systems of care for criminals with primary and acquired forms of mental illness.

Locking all of those people up in jail and restricting their access to medical care is good for business, but it is no way to treat human beings.



George Dawson, MD, DFAPA

Supplementary 1:  "In 2006 there were 228 state hospitals operating some 49,000 beds."

Fisher WH, Geller JL, Pandiani JA. The changing role of the state psychiatric hospital. Health Aff (Millwood). 2009 May-Jun;28(3):676-84. doi: 10.1377/hlthaff.28.3.676. PubMed PMID: 19414875.

Public Sector Mental Health Continues to Be Squeezed Out Of Business

There was a story that shocked many in the local press earlier this week.  A local mental health center serving about 3,000 people in five counties shut its doors, leaving nobody to fill that void.  Although this appears to be scandalous news, it is really the logical progression of events that has been accurately described in E. Fuller Torrey's book.  It is the logical result of federal and state governments selectively rationing mental health benefits and closing down both inpatient bed and outpatient treatment capacity.

People always ask me: "Well - what should an ideal community mental health center look like?"  That is easy for me to answer because I was trained in community psychiatry, my first job out of residency was as the medical director of a community mental health center (CMHC) , and most of my career has been focused on helping patients who are largely in the public sector or certainly funded by those resources (Medicare/Medical Assistance).  I know exactly what an ideal CMHC needs to run and provide services to a broad range of people who do not have access to metropolitan style mental health services.  The vignettes provided in this article will also be addressed in the following points.

1.  The backbone of any CMHC should be services that focus on people with disabling mental illnesses and helping them live independently.  In the state where my original CMHC was located, statutes defined these conditions as schizophrenia, bipolar disorder, schizoaffective disorder, major depression, and borderline personality disorder.  Adequate resources to treat those conditions generally means nursing and case management services that can meet with people in their homes and in the community.  In the teams that I worked with over 20 years ago we also had a vocational rehabilitation component and we worked with a number of physicians and specialists to address medical problems.  In any treatment setting where a CMHC is responsible for treating all public patients over a county wide catchment area, there is of necessity a legal component.  That is typically focused on involuntary treatment like civil commitment, court ordered medications, guardianships, conservatorships and protective placement.  Depending on the size of the county it can also involve competency assessments for ability to proceed to a court hearing based on concerns about mental illness.

2.  A community trained psychiatrist with medical skills.  The psychiatrist involved should enjoy working with people with people who have severe mental illnesses and medical comorbidity.  The legal component of services means that this person also needs to be comfortable doing the necessary exams and court testimony.  Medical and neurological illnesses need to be recognized and treated.  In CMHC settings the psychiatrist generally has much more information available about the health of his or her patients and they know how to interview people to get it.  When I was a medical director I also provided consultation to nursing homes, hospital consultations, and I would also travel to patient homes with case managers to provide consultation in that setting.  A lot depends on geography and distances to the other facilities needing consultation.

3.  Psychotherapists are critical to the functioning of a CMHC.  It has been interesting to watch the government and managed care companies ration psychotherapy services as much as they ration access to psychiatrists.  Correct me if I am wrong but as far as I know there are no HMOs or MCOs offering standard research based psychotherapies for psychiatric diagnoses.  At the max, usually 2 or 3 "crisis counseling" sessions.  In some cases a generic dialectical behavior therapy (DBT) group where many people with personality disorders end up because more specific therapy is unavailable.  CMHCs could be leaders in the implementation of computer based therapies, and the argument against that would be the lack of information technology departments.  The argument in support of this would be the fact that all counties across the state could share the same resource.  With today's tech, it would be  easily scalable to support anyone who needed it.  It would be inexpensive, effective and a good way to not dilute the psychotherapy resources of the clinic.  The other major change int he past two decades has been the focus on psychotherapy for people with severe mental illnesses.  That should be a critical part of any CMHC function.
 
4.  Addiction treatment - many communities have more resources available outside of the CMHC for assessment and treatment or referral of addictions.  The CMHC resources need to be more focused on the issue of co-occurring disorders and probably chronic pain and co-occurring disorders.  This would be another opportunity for networking all of the CMHCs in a state to assure a standard of assessment, share treatment resources, consult on specific cases and assure that there is no deterioration in prescriber standards with regard to potentially addictive medications.

5.  Crisis intervention services - 24/7 availability is necessary to provide acute evaluations but more importantly to resolve crises in patients who are well known to treatment teams.  Ity reduces the likelihood of unnecessary hospitalizations when there are staff person available who know the  person in crisis very well.  It is much more efficient and patient centered than sending a person to an emergency department and asking them to start over there with professionals who do not know them.

In the CMHC I worked in we had a catchment area of about 100,000 people spread over a large rural county.  We had a little over 100 patients in our community support programs for the severely disabled.  We we staffed by 1 psychiatrist, 2 psychologists, 4 social workers, 1 occupational therapist,  4 psychotherapists, 1 RN, and 2 LPNs.

The progression noted in this article is very clear and it has been replicated thousands of times across the US.  Shut down the large hospitals and tell people that treatment will be available in the communities near their homes.  Then shut down community treatment.  You will notice that officials make it seem like this is some kind of mystery.

“We’re so tight in [psychiatric] beds that any change in the delivery system impacts the whole system,” said Assistant Human Services Commissioner David Hartford. “The agencies need to reorganize to get people the care they need.”

Sorry Commissioner but in case you didn't notice we are not talking about beds anymore.  All of the people involved here were living at home in their own beds.  Agency "reorganization" is not an option.  There are no agencies anymore and one that was providing a valuable service was just shut down.  The problem here is very clear, cost shifting by managed care and defunding by the state.  Corporate welfare in the form of a carve-out for psychiatric services.  Keep in mind that when the comprehensive and humanistic approach to community treatment is lost, the only alternative is going in to a large managed care clinic where the appointments are scheduled every 15-20 minutes, the focus is on a prescription, and the only thing the doctor knows about what is going on is exchanged in that visit and recorded in the electronic health record.  That is frequently a symptom checklist. 

I guess there is always the psychiatric hospital of last resort - the county jail.  At least until the Sheriff's department goes broke.

George Dawson, MD, DFAPA

Christopher Snowbeck.  Crisis mental health provider closes; 5 counties scrambling.  TwinCities.com  St. Paul Pioneer Press.  March 18, 2014.

Chris Serres.  Minn. mental health center shuts down, stranding thousands.  Minneapolis StarTribune.  March 17, 2014.

Supplementary 1: I e-mailed the author of the first article Mr. Serres to inquire about the recently released state report that he refers to in the article and got no response.  As far as I can tell it may be the "Health Services in State Correctional Facilities Report" available at this site.  The concerning highlights include the fact that there are units that provide intensive nursing and mental health services.  About 33% (67,456) of all of the health services encounters with staff are for mental health purposes.  That translates to 28% of the offenders receiving mental health services.  At some point in their stay 32% are diagnosed with a "serious and persistent mental illness" as defined by state statute.  The report provides an interesting overview of how mental health services are provided in Minnesota prisons and the special problems involved in treating mentally ill offenders.

Supplementary 2: According  to Minnesota Statutes 2013, 245.462, subd. 20(c)(4)(i), states that a person has serious and persistent mental illness if he or she is an adult and “has a diagnosis of schizophrenia, bipolar disorder, major depression, schizoaffective disorder, or borderline personality disorder.”

The Medicaid Emergency Department Study

There is an important study on the emergency department (ED) and health care policy in the January 17 edition of the journal Science. It looks at the question of whether not health insurance increases or decreases ED use.  This has been a political football for years.  The debate has been that increased insurance enrollment would prevent excessive ED utilization but the evidence has been sparse.  Some surveys have shown that the uninsured view the high cost of ED services and the financial repercussions are a deterrent.  On the increased utilization side is the economic argument that prepaid services lower the cost and therefore increase the use of all medical services across the board.  Another variable is the overall economy.  In an economic downturn, people use less goods and services including medical services.

Mapped onto the ED utilization problem is the EMTLA law or The Emergency Medical Treatment and Labor Act.  This law states that no person requiring medical stabilization can be turned away from an ED based on ability to pay.  A variety of mechanisms shifts the cost of care to the facility and physicians providing the care.  In the case of psychiatric services, EDs are obligated to find an open bed to transfer the patient.  In most states the majority of hospitals with EDs do not have psychiatric units, and that can result in patients being held for long periods of time until a bed opens up or transfer to beds across the state.  More radical solutions to that problem have included discharging a person untreated back out to the street or discharging them after a certain time interval if a bed could not be identified.

The scope of the problem of psychiatric services in the ED has not been well studied.  Some of the large studies suffer from an inadequate look at diagnoses, crisis care, patient flow and disposition and outcomes.  Before this study, I could not find any studies with adequate detail about diagnoses.  The other consideration is selection bias.  In most metropolitan areas, emergency services brings patients with psychiatric crises to identified hospitals with the largest psychiatric services.  These services typically have large capacity and become catchment areas for large areas of the states they are located in.  They can also be overwhelmed due to various factors that affect patient flow.  Most of these factors are directly related to the closure and rationing of psychiatric services in acute care but also residential facilities, clinics and community support services for the severely disabled.

The design of this study is interesting because it is randomized based on a political initiative.  In 2008, Oregon started a limited expansion of Medicaid.  They drew 30,000 names from a pool of 90,000 people.  There were 8 drawings between March and September 2008.  Previous studies on outcomes by the same authors showed that Medicaid assignment led to reduce depression and improved general health but it did not impact several general measures of general health, employment, or earnings.  In this study they looked at 12 hospitals that are the catchment area for Portland and surrounding suburbs.  These hospitals have half of the annual admissions in the state.  The study ran for 18 months, and was an intent-to-treat analysis of the randomly selected Medicaid enrollees and the non-selected matched on demographic variables.

The primary result of the study showed that Medicaid enrollment was associated with a significant use in ED services.  The increase was 41% relative to the control group.  There was no difference in the number of visits resulting in admission but increases in most other types of visits, including those that would be treatable in an outpatient clinic.  For some reason these differences were detected in administrative but not self reported data.  The authors look at three potential reasons for those differences.  The discussion of study limitations focuses primarily on the fact that the low income population studied may differ significantly from other low income populations and limit its generalizability.  The author's also comment on how establishing primary care can logically increase the likelihood of ED utilization.  The commonest scenario there is a patient with with either risk factors or chronic illnesses that calls their primary care clinic and is advised to go to the ED because of the anticipated length or complexity of the required evaluation.   That factor could not be studied with the available data.  In the case of psychiatric services that is typically a change in mental status, suicide risk , aggressive behavior or need for intoxication or detoxification.

One of the features of this study of interest to psychiatrists is the supplementary data.  Table S10 lists "Select Conditions (control sample only)" for a total of 17,498 ED visits separated by category.  A total of 1346 or 8.4% of all visits were for "Substance abuse and mental health issues."  Of that sample, 3% were mood disorders, 2% alcohol related disorders, 1.5 % anxiety disorders, 0.9% schizophrenia and psychotic disorders, and 0.8% substance related disorders.  In looking at visits per condition increased ED utilization occurred for injuries, headaches, and chronic conditions but not mood disorders or substance use or mental health disorders.  It is not possible to see the distribution of ED visits by hospital and with what is known about these distributions on metro areas it is likely that a few of the 12 hospitals had most of these visits.

In the weeks to come, I anticipate that there will be an active debate on the economic and political implications of this study.  From a psychiatric perspective it does not really capture the scope of the problem of how we got to the current predicament of discharging people with psychiatric and substance use problems untreated from emergency departments.  Nobody seems to consider that the ED problem exists as a result of rationing at multiple levels and a physician productivity model that values a stereotypical low to moderate complexity visit.  Most clinics and even urgent care settings have limited flexibility to assess some of the suggested ED problems like new chest pain even though in this study 93.1% of the chest pain assessed was nonspecific and 3.5% represented an acute myocardial infarction.  A few conclusions that I come to:

1.  This study is well done, unique and seems to have a highly significant finding that increased insurance to a low income population leads to increased ED utilization rather than less.  Caution is needed in the interpretation of that data.  A major weakness of any study like this is the fact that it is all of the data is administrative rather than clinical.  This is a major weakness of practically every data set used to establish health care policy in the past starting with the RAND studies on overutilization of hospitalizations and procedures relative to what was determined by the PROs of the 1990s.  These studies showed that when the data was reviewed by non-biased reviewers with no conflict of interest, there was minimal to no overutilization.  It is probably time to consider that we need better data.

2.  All elements in the system are not equivalent - no 2 EDs are the same.  In any state you can walk into an ED attached to a Level 1 trauma center and burn unit or one that is staffed by moonlighting physicians or residents who may not be emergency medicine specialists.  That will naturally affect referral patterns and overcrowding phenomenon.  Detailed patient flow pattern in and out of the busiest EDs with enough granular data about that phenomena is probably more important in addressing the problem than a look at a single global insurance decision.  Data in this study and others suggests that the increased ED use is based on rational decision making about medical conditions and previous surveys on wanting to avert a financial catastrophe.

3.  Targeted interventions to reduce ED use is specific populations are highly effective.  Assertive Community Treatment (ACT) teams for people with chronic mental illness are a good example.  In these interventions teams have their own crisis programs independent of EDs as well as medical staff who are available to the patients 24/7.  Their goal is also to avoid psychiatric hospitalizations and they are very good at that.  As clinics are acquired and consolidated under various managed care organizations the likelihood of consulting with a person from your primary care clinic after hours decreases significantly and that probably means more contact with the ED.

4.  Urgent Care facilities are a logical extension of primary care clinics after hours and there is currently no psychiatric equivalent.  A clinic with adequate multidisciplinary mental health staff would seem like a better options than being seen in an ED.  There currently do not appear to be any facilities like this for mental health other than county government based crisis lines that vary considerably form county to county.

Despite all of the considerations I have listed above and more, I do not expect a more sophisticated look at this issue.  Our politicians are incapable of it and the conflicts of interest related to the business side of medicine will typically carry the day.  There will be some ideological arguments about economic theory but in the end, what is good for business will carry the day.

Increased utilization of the ED is looking better and better for business every day.    

 

George Dawson, MD, DFAPA



1: Taubman SL, Allen HL, Wright BJ, Baicker K, Finkelstein AN. Medicaid increases emergency-department use: evidence from Oregon's Health Insurance Experiment. Science. 2014 Jan 17;343(6168):263-8. doi: 10.1126/science.1246183. Epub 2014 Jan 2. PubMed PMID: 24385603.

2: Fisman R. Health care policy. Straining emergency rooms by expanding health insurance. Science. 2014 Jan 17;343(6168):252-3. doi: 10.1126/science.1249341.  Epub 2014 Jan 2. PubMed PMID: 24385605.

The News Media and Mental Illness - A Continued Problem

Although the media can certainly pump up the volume on trivia like the DSM-5 their coverage of the critical day-to-day issues involving mental illness continue to be lacking in both depth and breadth.  It is weak.  From a depth perspective I will point to an article about a man convicted of shooting at people on the I-96 freeway in southeastern Michigan.  His reason for the shootings?  He thought he was getting coded messages from the Detroit Tigers to shoot people.  He also believed that military helicopters were hovering above his home and that his home contained "advanced technologies" that caused his daughter to develop a skin disease and his wife have a miscarriage.  The article contains a layman's description of a not guilty by reason of mental disorder defense and that defense was never advanced based on a judges ruling.  As a psychiatrist familiar with these criteria there is an overwhelming bias to convict people who are mentally ill and mentally compromised.  That is why the defense is generally a failure.  In this case the defendant did not have the opportunity to present that defense because as the article explains:

"Diminished capacity is a claim that says a defendant was unable to form specific intent required to commit a crime under the law by reason of mental illness, and as a result, the defendant’s responsibility in the alleged crime is diminished. The judge earlier ruled that the defense could not make this argument because it failed to give proper notice of a defense of insanity."

In other portions of the article we learn that he has been treated for an unnamed mental illness since 2009.  The symptoms are described as delusions that respond to medication and the delusions associated with the shooting incidents are currently in remission.  When the defendant is asked about whether he knew that firing a gun into an automobile might hurt someone.  His response was "In hindsight - yes".  I have not seen the final sentencing after a no contest plea but he faces up to 12 years in prison on firearms and assault charges after they decided to drop a terrorism charge.

From a breadth of coverage perspective, I will suggest a second article that points out the critical shortage in acute care inpatient beds with the capacity to address severe mental illness and aggressive behavior.  In those case Virginia State Senator Creigh Deeds discusses an incident where his son stabbed him and subsequently shot himself.  After the incident Senator Deeds states that the read his son's diary and it said that if he killed his father he would go directly to heaven.  In his taped discussion he talks about all of the relevant points that I try to cover here involving stigma, a lack of respect for providers, and diversion of resources to more areas of care that are viewed as more prestigious - like Cardiology.  Amazingly, Virginia apparently has a rule where you must be released from the emergency department if they can't find a psychiatric bed within 6 hours.  Based on his proposed reforms it doesn't seem like there has to be much of an effort to look elsewhere.  The sequence of events has been managed care companies shutting down psychiatric bed capacity by defunding it.  That is followed by states deciding to act like managed care companies and either shutting down their capacity or getting completely out of the field.  The end result is a pool of people who cycle in and out of short stays on inpatient units to overcrowded emergency departments to the street and back again.  Many permanently drop out of that cycle when they become homeless or go to America's newest mental hospitals - the county jail.  This is a problem everywhere in the United States.  I used to qualify that by saying it was a problem in areas of high managed care penetration.  Today that is everywhere.

Apart from the isolated pieces that are written with the obvious intent to get somebody a Pulitzer Prize, these stories are typical of what you see in the press.  The first article lacks basic information on what mental illness is and how decision making in a delusional state bears no resemblance to answering questions "in hindsight" after the delusions are gone.  It lacks psychiatric perspective.  Any newspaper reporter probably has access to acute care psychiatrists to tell them about those problems.  In that situation reporters always want a "diagnosis" of the person in the news and psychiatrists cannot speculate on that without having examined the patient and getting their release for that information.  But they can provide a rich perspective based on their clinical experience treating thousands of similar problems and the effect of delusions on a person's conscious state.  They can also provide an opinion on the mental illness defense in this country as well as the state of psychiatric services to treat the problem.  I know that I would be happy to provide those details.  At the minimum somebody in charge of journalism school curricula needs to examine how reporters can come out and ignore all of those facts.  I might even suggest objective criteria for coverage as at least 5 times the words used to cover the least relevant mental illness story that year.  I would give the least relevant story this year as anything having to do with the DSM-5.  On that basis a lot of additional writing needs to be done on these two stories.

In the case of Senator Deeds, his analysis of the problem in this brief soundbite is spot on.  He needs a broader platform to advocate for his plan and support against the people who are opposing him and the 6 hour rule in state of Virginia.  He should work the the American Psychiatric Association, receive their support, and have access to their social media venues.  The APA should come out with their own solution to this problem.  I cannot think of anything more absurd and more consistent with a managed business approach to treating severe health problems than this 6 hour rule.  At some point the patient and their severe problem is totally meaningless relative to business concerns.  And Senator Deeds is right.  That doesn't happen with any other medical problem in the emergency department.

It only happens with mental illness.

George Dawson, MD, DFAPA

It Is Cold Outside

I was driving into work this AM. I drive a six year old Toyota Van. The thermometer on my rearview mirror hovered between - 20 and -21 Fahrenheit, but every bank I passed said -24. Before I left home this morning I added a layer of polyester, packed additional headgear, and wore my Sorel boots. This is serious weather even if you are born and raised here and you need to be prepared for the worst. Standing outside for even a few minutes without adequate cover can result in frostbite or worse. The Governor of Minnesota closed down all of the schools today to prevent frostbite injuries and so far there have been no arguments with that decision.  The drive home at night was slightly warmer at -16 degrees.  The sky was so clear it was like being in outer space.  I had to stop for gas and the driver's side door froze open.  I had to hold it shut for about 6 miles until it thawed to the point I could slam it.

Apart from the pragmatics of winter survival, the cold weather also triggers a lot of associative memories - starting with my Sorels. I got these boots originally in 1971 in order to do a Limnology experiment on Lake Superior.

A friend of mine helped me and we went out onto the ice for a about 5 hours and pumped about 200 gallons of lake water through a plankton net to look at the winter plankton population. It was about -5 degrees that day. A few years earlier he had a case of frostbite after walking about 10 blocks to school wearing nothing but a pea coat.  Like a lot of people in the northern US and Canada, I have found that these boots absolutely protect your feet in subzero weather.

I lived in Duluth, Minnesota for a while and can recall trying to speedskate when it was -10 to -15 degrees. At that temperature, a skate blade cannot compress and liquefy the ice enough to support much glide so the skating motion and its mechanics are seriously disrupted. I was wearing two layers of polyester, a layer of Lycra, and a layer of fiber.  Unlike Sorels - speedskates even with neoprene boot covers don't protect much against the cold.  When I got home I had to lay on top of a radiator under a blanket for 30 minutes in order to warm up. The coldest I have ever been in the winter usually happens after falling through the ice. I can recall walking across a creek and just getting ready to step up onto the far bank when I fell through the ice up to my chest in icy water. The sensation that occurs when that happens is incredible. Your breathing stops for a while followed by rapid gasping as you struggle to get out of the water. That is followed by the desperate run home. In my case it was only about 7 blocks and by the time I got there my clothes were frozen solid.  A friend of mine was skating on Lake Superior and fell through the ice catching himself only by his fingertips. He ran home about the same distance but he had been totally submerged.

My more recent memories are about how the cold has been a factor in my role as a psychiatrist. Most psychiatrists in the Midwest have first-hand experience with the complications of cold weather. We have seen people with frostbite injuries both on burn units and after they have been transferred. We know many of the people who are caught in the endless inpatient unit -> emergency department -> homeless cycle that seems like a permanent artifact of our managed care inpatient and county mental health systems. We have seen the human interest stories that tend to run in the papers when the potentially lethal cold weather hits and the temporary concern about whether or not there are enough shelter beds.

Weather this cold does not allow you to make a lot of mistakes. Sometimes all it takes is the idea that you can run out to the trash can without putting on a jacket and finding that you have locked yourself out of the house. People with memory problems and disorientation can wander off and get lost. People with drinking problems can pass out or just take too long to get home. All it takes is a decision that keeps you out in the subzero weather for minutes too long and you can be in serious trouble.

Potentially lethal cold weather is also an integral part of treatment decisions. You can't really watch people coming in to appointments wearing summer clothing in this weather without doing an assessment for cold weather safety. It becomes part of the discharge decision making. Exactly how stable is the person's housing and how likely are they to keep themselves safe? Can they walk 10 blocks from the hospital to their apartment wearing a sweat suit, basketball shoes, and no hat?  Should they be discharged to the street, even if they want to be?  Should they be discharged if a managed care reviewer says that they should be discharged?  We are generally talking about people who have chronic problems with insight and judgment.  What about people with suicidal ideation? What about the person with chronic drug problems who has a history of drug induced blackouts and waking up on park benches?  What about the person with Alzheimer’s disease who does not have 24 hour supervision?   

How do you make an unbiased decision in that context?  I can say that you don’t.  You don’t because as a psychiatrist you are aware of all of the adverse outcomes.  The continuum of severe frostbite injuries to the hypothermic who could not be resuscitated to those who were found frozen to death.  You don’t want to see that happen to anyone.  You don’t care if somebody wants to call that paternalistic.  You don’t really care if it costs a managed care company or (more likely) a hospital a few bucks.  You have been there yourself and you know you cannot take any chances in subzero weather.  It’s not about a fear of being sued, it’s about concern for a fellow human being.

There are implications for the imminent dangerousness standard that is commonly applied to involuntary holds.  I have argued with enough county attorneys over the years to understand that the standard itself is purely subjective and arbitrary.  No matter how it appears on paper you will hear ten different interpretations from 10 different county attorneys.  There are a few states where a gravely disabled standard applies.  That standard states that a person may have problematic judgment to the point that it potentially impacts their ability to secure adequate food, medical care, or housing.  That standard probably generally applies in these situations, but if you happen to be in a state where there is no statute or the county courts ignore it for convenience or financial reasons it may not be available for use.  

Those are the kinds of things I think about when it gets this cold.  I do get the occasional lighthearted thoughts – making sure I recall the thermodynamic equations that show my car battery dependent on temperature and telling myself that I am going to call Columbia and ask them if they make some type of expedition wear that is warmer than my current Titanium coat.  But mostly – I hope the most vulnerable among us get the help they need and nobody gets injured or killed.  Hopefully someday people will think about the fact that some people have a hard time protecting themselves - irrespective of the air temperature.

George Dawson, MD, DFAPA

Andy Rathbun.  Regions Hospital Sees "Record-Breaking" Number of Frostbite Cases.  St. Paul Pioneer Press.  January 6, 2013.

From the article:

"Most of the people that come in with severe frostbite are "in some way compromised," he said. A small number are physically or mentally disabled, but a majority are people who have consumed too much alcohol or were abusing drugs and didn't realize how cold it was outside, Edmonson said."
             

Straight Talk About the Government Dismantling Care for Serious Mental Illness

The ShrinkRap blog posted a link to an E. Fuller Torrey and D.J. Jaffe editorial in the National Review about how the government has dismantled mental health care for serious mental illnesses and some of the repercussions.   Since I have been saying the exact same thing for the past 20 years, they will get no argument from me.  Only in the theatre of the absurd that passes for press coverage of mental illness and psychiatry in this country can this subject be ignored and silenced for so long.  It was obviously much more important to see an endless stream of articles trying to make the DSM-5 seem relevant for every man.  The stunning part about the Newtown article is the commentary about what government officials responsible for policy have actually been saying about it.

The authors waste very little time examining the sequence of events in the Obama administration following the Newtown, Connecticut mass shooting.  President Obama initially stated he would "make access to mental health care as easy as access to guns." and set up a Task Force under Vice President Biden to make recommendations.  The authors argue that the agency that was consulted, the Substance Abuse and Mental Health Services Administration (SAMHSA) promotes a model of treating mental illness that has no proven efficacy, does not discuss serious mental illnesses in its planning document, ignores effective treatments for serious mental illnesses and actually goes so far as to fund programs that block the implementation of effective treatment programs.  In an example of the obstruction of effective programming by SAMHSA funded programs following the Newtown mass shooting:

"But, alas, the situation is even worse. SAMHSA does not merely ignore effective treatments for individuals with severe mental illness. It also funds programs that attempt to undermine the implementation of such treatments at the state and county level. One such program is the Protection and Advocacy program, a $34 million SAMHSA program that was originally implemented to protect patients in mental hospitals from abuse. It was kidnapped by civil-liberties zealots and has been used to block the implementation of assisted outpatient treatment, funding efforts to undermine it in at least 13 states. For example in Connecticut, following the Newtown massacre of schoolchildren, the federally funded Connecticut Office of Protection and Advocacy for Persons with Disabilities testified before a state-legislature working group in opposition to the proposed implementation of a proposed law permitting court-ordered outpatient treatment for individuals with severe mental illness who have been proven dangerous. The law did not pass."  (page 3, par 2.)

In other words, a SAMHSA funded program was opposed to a law in Connecticut that could potentially reduce violence from persons with severe mental illness.

SAMHSA administrators are quoted at times in the article. Any quote can be taken out of context but the characterizations of severe mental illness as "severe emotional distress", "a spiritual experience" and "a coping mechanism and not a disease" reflect a serious lack of knowledge about these disorders.  The idea that "the  covert mission of the mental health system ...is social control" is standard antipsychiatry philosophy from the 1960s.  How is it that after the Decade of the Brain and the new Obama Brain Initiative  we can have a lead federal agency that apparently knows nothing about the treatment of serious mental illnesses?  How is it that apart from  some fairly obscure testimony, no professional organizations have pointed this out?  How is it in an era where governments at all levels seem to demand evidence based care, that a lead agency on mental health promotes treatment that has no evidence basis and ignores the treatment that is evidence based?

Having been a long time advocate for the prevention of violence by the treatment of severe mental illnesses my comments parallel those of the authors.  Inpatient bed capacity in psychiatry has been decimated.  They point out that there are only 5% of the public psychiatry beds available that there were 50 years ago.  It is well known that people with mental illnesses are being incarcerated in record numbers and some of the nation's county jails have become the largest psychiatric institutions.  Where are all of the civil liberties advocates trying to get the mentally ill out of jail?

Only a small portion of the beds available can be used for potentially violent or aggressive patients and that number gets much smaller if a violent act has actually been committed. Most of the bed capacity in this country is under the purview of some type of managed care organization and that reduces the likelihood of adequate assessment or treatment.  The discharge plan in some cases is to just put the patient on a bus to another state.

Community psychiatry is a valuable unmentioned resource in this area.  In most of the individual cases mentioned in this article, the lack of insight into mental illness or anosognosia is prominent.  It is not reasonable to expect that a person with anosognosia will follow up with outpatient appointments or even continue to take a medication that treats their symptoms into remission.  Active treatment in the community by a psychiatrists and a team who knows the patient and their family is the best way to proceed.  All of this active treatment has been cost shifted out of insurance coverage and is subject to budget cuts at the county and state level.

Civil commitment laws and proceedings are probably the weakest link in treatment.  Further cost shifting occurs and violent patients often end up aggregating in the counties with the most resources.  Even while they are there, many courts hear (from a budgetary perspective) that they are committing too many people and the interpretation of the commitment law becomes more liberal until there is an incident that leads to the interpretation tightening up again.  Bureaucrats involved often become libertarians and suggest that commitment can occur only if an actual violent incident has happened rather than the threat of violence.

Although Torrey and Jaffe are using the extreme situation of violence in the seriously mentally ill to make their point, the majority of the seriously mentally ill are not violent.  They need the same resources.  It has been thirty years of systematic discrimination against these people, their families and the doctors trying to treat them that has led to these problems.  I pointed out earlier on this blog the problem I have with SAMHSA and the use of the term "behavioral health".  The problems with SAMHSA and current federal policy are covered in this article and I encourage anyone with an interest to read it.  If history is any indication, I don't expect anything serious to come of the criticism.  I anticipate a lot of rhetorical blow back at Dr. Torrey.  But as a psychiatrist who has worked in these environments for most of my career, his analysis of the problem is right on the mark.

George Dawson, MD, DFAPA

E. Fuller Torrey & D.J. Jaffe.  After Newtown.  National Review Online.

White House.  Now Is The Time.  The President's plan to protect our children and our communities by reducing gun violence.  January 16, 2013.

Why reform of the mental health system is hopeless.

I debated putting "reform" in quotes.  The term has essentially become meaningless.  I have been hearing about health care reform for over 20 years and things continue to get worse and worse.  They get worse at a much faster rate whenever mental health care reform is considered.  I won't belabor the facts that I have already listed here before, but I witnessed an event yesterday to highlight why any reform of the mental health system is completely hopeless at this point.

The event was a panel discussion entitled "Many Perspectives on Patient-Centered Care and Building a Stronger Mental Health System".  There were 5 panelists including two psychiatrists, a local celebrity, a reporter, and a mental health advocate.  It was scheduled as a one hour event and I left at about the 1:05 point.  The hour began with the panelists disclosing their personal experiences with the system and what that seemed to imply for reform.  There were stories about a system that is fairly refractory to input.  Psychiatrists can't get people hospitalized when it is a true emergency, the family can't get input into the clinicians treating their loved ones, and there is minimal if any cross talk among physicians.  There were two stories of misdiagnosis, in one case over a period of 20-30 years.  The problem of documentation came up and the fact that there seems to be "no narrative" any more about the patient's diagnosis and problems - only check lists and electronic health record forms.

After the initial presentations the audience got involved.  The audience was essentially all psychiatrists and the solutions were predictably more infuriating anecdotes, workarounds, and tales of the one unique person who might be able to save the day.  From the panel, the advocacy standpoint seemed to be that progress was being made and that no more hospital beds were necessary or at least they should be discussed as an absolute last resort since they are the most expensive treatment option.  That discussion focused on a point by an audience member who I would consider to be one of the top experts in child and adolescent mental health in the state when he mentioned there were only "2.5 acute care beds in the State" available for children in crisis.  I may have missed the actual solutions because I had to leave the meeting.  I have seen meetings and panels like this before and they go nowhere.

So what is the problem and what can be done about it?

The problem is quite simply managed care and all of its permutations.  I waited for 65 minutes and nobody uttered the word.  Managed care and all of its special interests is directly responsible for the ridiculous time constraints on clinicians.  There is no time for a complex diagnostic evaluation much less time to talk with the family.  It is responsible for the rationed inpatient beds and the lack of bed capacity.  It is responsible the fact that systems of care are set up to optimize cash flow to large health care organizations rather than the quality of care.  There is perhaps no better example than what currently passes for inpatient psychiatric care.  We currently have case managers running the care of hospitalized patients and telling their psychiatrists when to discharge them.  I talked directly with an inpatient psychiatrist the other day who told me that case managers and social workers at his hospital frequently have the discharge plan set up before he sees and assesses the patient.  They simply tell him that the patient can be discharged.  All in the service of making sure that nobody extends beyond the DRG payment and the hospital continues to make money.  Inpatient units seem to have become holding tanks for people to sit around until they are "cleared" for discharge.  That typically involves sitting around on a secure psychiatric unit and answering questions about whether or not you might be "suicidal" until you can be released.   All of this flows from the ridiculous managed care concept that "dangerousness" is the only reason people need to be on a psychiatric unit.  All of that occurring at a time when mental health advocates are concerned about stigmatizing the mentally ill as violent.  Is it possible that psychiatrists have become so hopeless about reversing the trend of business friendly but otherwise irrational rationing that they avoid even talking about it anymore?  I think that is more than likely.

Outpatient care is not much better.  Some of the panelists were talking about the virtues of outpatient care where there is a team that knows the patient and everything is idyllic.  There is no reason to expect that an outpatient case manager is any more virtuous than an inpatient one.  I have talked with many psychiatrists who notice that their care is basically completely marginalized by low to mid level bureaucrats who have no professional responsibility to the patient.  I have be pointing this out for 20 years and recently other physicians are also  talking about the problem.

As long as you pretend that making money off rationing your care and treating you is not a conflict of interest - the system will continue to deteriorate.  As long as nobody acknowledges that psychiatrists have been looking at "cost effective" care in the rear view mirror for the past 20 years - reasonable change is impossible.  As long as nobody in the room can clearly say "First of all there is no system and second, managed care and the associated rationing and low quality are the real problems here" - reform will remain meaningless political rhetoric.

George Dawson, MD, DFAPA

Jerry A. Singer, MD.  How Government Killed the Medical Profession Reason May 2013.

NYTimes on Involuntary Treatment

The New York Times somehow let an all too true story about the treatment of mental illness slip through today instead of one of their more typical speculative pieces.  It is a story of a family desperately trying to get their father and husband assistance after he develops acute bipolar disorder with psychotic symptoms.  It is a reasonable discussion of some of the issues behind deinstitutionalization, involuntary treatment, and the sad state of affairs that currently exists in trying to get treatment for those with severe mental illness. 

Probably the best quote in the article follows:

“The lack of resources has triggered a devolution of the standard,” says Robert Davison, executive director of the Mental Health Association of Essex County, a nonprofit group that connects patients to services in northern New Jersey. “Twenty years ago, ‘imminent danger’ meant what most people think it means. But now there’s this systemic push to divert people away from inpatient care, no matter how sick they are, because we know there’s no place to send them.”

I will refrain from the typical term applied to the situations whose definition is: "a particularly bad or critical state of affairs, arising from a number of negative or unpredictable factors".  The reason I will refrain is that it is not exactly accurate.  The entire debacle has been totally predictable.  It is the predictable result of applying managed care rationing techniques to the private and public mental health sector and denying care to those people with the most severe forms of mental illness.  When your only perspective is rationing care to make money - there are no standards.

So  what are the solutions?

They are fairly straightforward.  First off, there needs to be reasonable commitment standards with a more appropriate balance than "imminent dangerousnessness".  From the article it is clear that even that standard is interpreted widely.  There needs to be a three part standard for danger to self, danger to others, and gravely disabled and not able to care for oneself.  Some states accomplish the same goals by separating civil commitment from protective services/protective placement statutes.  The latter approach has the advantage of avoiding the use of commitment courts for issues that come up in the course of Alzheimer's disease and other dementias.

Secondly,  the statutes need to be uniformly interpreted.  My experience working with probate courts from a 3 county area illustrates that no two judges would make the same decision on a particular case.  In many counties, the social workers screening the cases had much different philosophies.  The only time that changed was when there was a bad outcome.  That outcome was typically a person released by the court who attempted or committed a homicide or suicide.   

Third, there needs to be recognition that state hospital beds are not the only solution.  The main reason that state hospital beds don't work is that there are no local resources.  Once a person is ready for discharge, there is no place to send them.  More and more people accumulate at the state hospital and nobody is discharged.  There needs to be housing resources and community teams to actively work with people to facilitate discharge and maintain them in the community.   Just building state hospital beds has the predictable outcome of building more state hospital beds.

Fourth, financial conflicts of interest must be eliminated.  They exist at multiple levels and are the predictable outcome of rationing techniques that originated in the managed care industry 30 years ago.  The basic premise of managed care is that a "medical necessity" standard can be developed that will be subjectively interpreted by the company in order to ration care and save the company money.  One of the major loopholes has been any person that needs involuntary treatment.  The managed care company can simply say this care is no longer "acute" or "medically necessary" and transfer the financial burden of care to the taxpayers.  Huge cost savings to the managed care company.  That doesn't happen if you need a heart transplant.

The financial conflicts of interest occur at every level in the system.  Another example is the interpretation that at an aggressive or self endangering event has to have occurred in order to meet the commitment standard.  The author here does a good job of providing examples.  What is not obvious is the financial conflict of interest that is present in these situations.  In almost all cases - the hearing occurs  at the county level and the judge presiding knows the county's financial status and access to resources.  That significantly biases decisions especially in the case of counties where there are limited resources.

The only solution to avoiding these pure conflicts of interest is to have the money follow the patient and have it in a dedicated fund.  It is too easy to move funds around that should be designated for the treatment of severe mental illness if they move in and out of a general fund.  

Fifth, there need to be better managers of the systems responsible for the care of patients with severe mental illnesses.  Managed care companies clearly do a very poor job.  On the other hand every state generally has a large Department of Human Services and second to education they are usually the largest budget in the state.   Despite significant constant and high demands they are generally managed like any other state agency.  If there is a revenue shortfall and everybody has a 6% across the board spending cut, DHS also has a 6% spending cut.  These departments usually employ cost  center accounting that is also a detriment to coming up with an adequate plan of care across treatment settings.  Finally it is also common these days in both managed care and state systems to see managers with no clinical experience attempting to hold clinicians accountable to subjective standards and implementing plans to change care delivery - even though they have no expertise.

These are a few changes that would make a world of difference for families and patients like those mentioned in the NYTimes article today.  I am not very hopeful that they can happen because it would also involve changing a culture that has been the most insidious aspect of managed care.  That culture is quite simply - bureaucrats and business people telling psychiatrists what to do and restricting the resources needed to provide adequate care.

George Dawson, MD, DFAPA

Jennen Interlandi.  When My Crazy Father Actually Lost His Mind.  NYTimes June 22, 2012. 

Mismanagement of Knowledge Workers

In a previous post,  I discussed Drucker's concept of “knowledge workers” and how that concept applied to psychiatrists and physicians. The basic concept is that knowledge workers know more than their managers about the service they provide, work quality is more characteristic than quantity, and they are generally considered to be an asset of corporations.  I pointed out that physician knowledge workers are currently being managed like production workers and referred to common mistakes made in managing physicians and psychiatrists. Today I will tell attempt to describe how some of that mismanagement occurs using examples that psychiatrists have discussed with me over the past several years.

Inpatient psychiatry has taken a severe hit over the past 20 years in terms of the quality of care. Many people have talked with me about the discharge of symptomatic patients occurring in the context of high volume and low quality. Depending on the organization, a psychiatrist may be expected to run an outpatient clinic in addition to a busy inpatient service or in some cases provide all the medical services to the inpatients with minimal outside consultation. Most hospital care is reimbursed poorly despite political suggestions to the contrary. Psychiatric DRGs are typically 20% less than medical surgical DRGs and they are not adjusted for complex care. Administrators generally "manage" psychiatrists in a way to make sure that inpatient beds are covered. That frequently means that psychiatrists who prefer practicing in an outpatient setting end up doing some inpatient care. An outpatient clinic may be canceled so that a psychiatrist is available to run an inpatient unit. There have been situations where inpatient beds or whole units have been shut down for lack of psychiatric coverage. The only explanation given is that there is a "shortage" of psychiatrists.

I had the pleasure of running into one of my residency mentors in an airport last May. I let him know that I was just finishing up 21 years of inpatient work and moving on to something else. He smiled and said: "Three months wasn't enough?".  I always liked his sense of humor but there is also a lot of reality in his remarks.

I don't mean to imply that it is any easier on the outpatient side. If you are a manager, what could be easier than having a unit of production that you could hold your employees to? It turns out there is something easier and that is being able to set the value of that unit of production. That is what RVU based productivity is all about. A standard managerial strategy these days is to have a meeting with an outpatient psychiatrist and show them how much they are "costing the clinic" based on their RVU production. Spending hours a day answering phone calls, doing prior authorizations, questions from other clinicians, curbside consultations, discussions with family members, and documenting everything doesn't count. I have had the experience calling a clinic at 7 PM and hearing keyboards clicking in the background. I have asked outpatient colleagues how they are able to produce outpatient documentation themselves and still get out of clinic on time. Now that I work in an outpatient setting myself, I know what they were telling me was accurate and that is the documentation gets deferred until later.

The mismanagement does not stop there. At some point in time medical schools decided that there were also going to start basing faculty salaries on clinical production. I suppose every medical school as a formula for converting teaching and research time into production units, but until I see those formulas my speculation is that any activity that does not result in billing leads to lower compensation. The days when physicians were hired as teachers and academicians seem to be gone.  Because of discriminatory reimbursement, departments of psychiatry will be disproportionately affected.

Within psychiatry there used to be an interest in organizational dynamics and how they impacted patient care. The dynamics in most organizations today are set up to promote the business. That has produced a focus on high volume-low quality or in some cases supporting the specialty with the highest reimbursement and procedure rates.   Associated dynamics are in place to select and shape an idealized corporate employee who will modify his or her practice according to the whims of the Corporation. It may be hard to believe but large medical corporations everywhere are trying to figure out how to recruit young physicians who believe in their models. Physicians who don't accept these ideas frequently find that the company is not very friendly to them. There are always various political mechanisms for ousting any dissidents and there is minimal tolerance for debate.  The dissent can be as mild as asking why consultants with less expertise than the physicians in the practice are being called in to critique them and come up with a plan.

When it comes to physician mismanagement there are few businesses that can equal the government. RVUs, the Medicare Physician Payment Schedule, pay for performance, and various failed political theories like fraud as the cause for healthcare inflation, and managed care amplifying all of the above and focusing all of that irrational management directly on physicians.  The result is obvious as enormous inefficiencies, job dissatisfaction, and demoralization. Governments partnering with businesses and placing business practices like utilization review and prior authorization in state statutes increases the burden exponentially. At the heart of this conflict is a physicians training to be a scientific critical thinker and function autonomously with the businesses interest of making a buck. Despite all the lip service to quality, business decisions are always made on a cost rather than quality basis.

It is often difficult to see any light through the blizzard of government and business propaganda that passes for the management of physicians and psychiatrists. Psychiatry has bore the brunt of mismanagement over the past 20 years and that has well been well documented in the Hay group study showing the disproportionate impact of managed care on our field. Inpatient bed capacity has dwindled and the beds that have not been shut down are managed for high-volume low quality work. Outpatient clinics including those run by and nonprofits are managed according to the same model.  Businesses and governments have provided the incentives for this type of practice.  The available consultants in the field only know an RVU based productivity model and nothing else. Rather than treating psychiatrists as knowledge worker assets, the available jobs frequently reduce us to micromanaged clerical workers utilizing about 10% of our knowledge.  It should be no surprise that the environment makes it seem like anyone can do the job.

One of my favorite quotes from Peter Drucker was: "More and more people in the workforce and mostly knowledge workers will have to manage themselves".   After all, only  the knowledge worker knows how to best complete the job.  Every psychiatrist that I know, knows how to get the job done and it is often at odds with what we are allowed to do. The best pathway to do this is to optimize the internal states of the knowledge workers and create environment where they manage themselves.  There are very few environments available where that can happen today for psychiatrists.

George Dawson, MD

Is it the economy?

The lead story in this week's Psychiatric Times was sent to me in e-mail this morning under the subject "Economy Threatens Psychiatry Programs". It provides the news that the Cedars-Sinai Department of Psychiatry and Behavioral Neurosciences is essentially being phased out except for "staffing of psychiatric support that is an adjunct to patient care throughout the medical center." It quotes an unnamed academic psychiatrist as saying that the real reason that psychiatric programs are getting the axe is that they are the least profitable services offered at any hospital. The article goes on to suggest that declining Medicare funding of Graduate Medical Education may threaten additional programs.

The only real explanation and dose of reality in that article was the quote from their anonymous source. Psychiatric programs and bed capacity have been closing down for the past 20 years. It is the direct product of managed care strategies either being applied directly by the managed care cartel or through their friends and allies in the government. I have previously posted on this blog how psychiatric services have been marginalized from an economic standpoint.  That should be obvious from surveying any acute care hospitals in your state. In the state of Minnesota for example, a minority of the total hospitals have psychiatric units and fewer are staffed for chemical dependency services.  That has resulted in the need to transfer patients in crisis in emergency departments across the state or in some cases in different states. As a result any involved family members have to travel hundreds of miles to maintain contact with that person.  The economy for psychiatry has been bad for the last 20 years.

The evolution of this process is apparently so insidious that nobody pays attention to it. The only way that the minority of hospitals with psychiatric units can continue to operate and staff those units with psychiatrists is if they do a high volume, low quality DRG based business or they are subsidized to some degree out of the profit margin of other departments. In that case, an economic argument can be made that more severely ill psychiatric patients or medically ill psychiatric patients would never leave medical or surgical units if there were not psychiatric units available to receive them in transfer.

This process is easily reversed by providing adequate compensation for psychiatric care. The reimbursement levels for inpatient care are so trivial that an inpatient psychiatric unit is currently the least expensive place to maintain the patient.  At some point, treatment on a DRG based inpatient unit is cheaper than a group home and much cheaper than a state hospital.  That creates additional incentives and barriers to discharge from the hospital.

The bottom line is that it is not the economy.  There has been a systematic bias against mental health services for at least 20 years.  It is well past the time for psychiatrists and other advocates to remove the term "cost effective" from their dialogue. Psychiatric and mental health services have been the most cost effective medical services for at least the past 20 years and there is no reason for expecting them to get less expensive. Reversing that trend and providing compensation that is at least on par with the rest of medicine will allow for quality psychiatric hospital services and outpatient clinics.

George Dawson, MD

Stephen Barlas. Elimination of Psych Services at Cedars-Sinai Could Foreshadow Similar Cutbacks Elsewhere.  Psychiatric Times Vol 29, No2, February 8, 2012 

Endnote:  According to the Minnesota Hospital Association 29 of 136 acute care hospitals have beds staffed for mental health care and 6 of 136 have beds staffed for chemical dependency care.