I wrote this editorial in 2010 for the Minnesota Psychiatric Society newsletter Ideas of Reference as part of my role as the President at the time. It was subtitled: "A new approach is needed and I think that approach needs to be psychiatrists redesigning the system." Since then, things continue to go in the wrong direction. I still find the term "stakeholders" to be cringeworthy. The only stakeholders as far as I am concerned are physicians, patients, and their families.
Who are the real stakeholders when you are face to face
with your patient and you are being coerced into doing something that is not in
the patient's best interest? Where does the profession stand on this? For
almost two decades now we have been complacent while insurance companies,
government bureaucrats and politicians, and pharmaceutical companies have
directly intruded on the physician-patient relationship in a way that has
seriously impacted the resources available for patient care and the quality of
that care. The operative word is
complacency. I still have a habit that I learned from my freshman English
composition professor. I compulsively look up word definitions to make sure I
am using them correctly. I think you develop a lot of insight into your changing
knowledge base when you look up words that you think you know very well and
find that they seem to have taken on more important meaning. For me complacency
has become such a word. Looking it up in several dictionaries, the definition I
like the best is: "self-satisfied and unaware of possible dangers".
With few exceptions, that seems to be the position we have been in for the past
20 years.
I can't think of a better word to describe how physicians
were duped into believing that an RVU based pay system would somehow result in
better reimbursement for cognitive specialists. Or that coders could determine
who was submitting correct billing based on documentation, much less committing
fraud. Or that utilization review for inpatient stays and prior authorization
for medications is a legitimate practice. Or that managed care companies and
behavioral carveouts reduce health-care inflation. Or that the focus of
psychiatric assessment and treatment involves the prescription of a pill in
roughly the same time frame that an antibiotic could be prescribed for otitis
media. The list of things that we've been complacent about is long and it is
growing every day.
For those psychiatrists working in institutions, committees
are often a starting point. Much of the time, committees and meetings focus on
issues that are peripheral to patient care and quality care. They rarely focus
on the actual practice environment for the psychiatrist and the patient. In
many cases, the fatal flaw is that the people making the major decisions are
not in the meetings. The meetings are frequently held to make it seem like
physicians actually have input into what is going on. At times the physicians are
prepared by someone telling them that the old days in medicine are dead. The
implication is that physicians used to be all powerful, now they are not, and
in fact they should expect to have the equivalent input of any other employee.
The strategies we have observed for dealing with a broad
array of stakeholders at the table have all been inadequate. We have allowed
stakeholders with clear conflicts of interest to suggest that we are more
conflicted than they are. The only solution is to be clearly differentiated from
everyone else. We are squarely focused on assessing and treating patients in an
ethical manner and any political initiative that we endorse or participate in
should be consistent with that focus.
What does this mean in a practical sense? First off, it
means coming into a meeting with a clear position rather than showing up to
broker a deal. It means prioritizing patient care over profits from rationing
or political gain from rationing. It means pointing out that the
physician-patient dyad is in no way equivalent to any other political agenda in
the room. It means not signing off on the status quo when we are the only
people in the room speaking to the interests of physicians and their patients.
The recent changes to the way that psychiatric care is
delivered to the state's low-income population illustrate all of the problems.
Patients with GAMC have significant psychiatric comorbidity, and, even prior to
the cuts by Governor Pawlenty, were also subjected to more rationing by private
and government payers than other patients. The ultimate change, in the form of
Coordinated Care Delivery System (CCDS) clinics, takes this rationing to a
whole new level. At the same time the state has attempted to reinvent the state
hospital system. Both of these changes disproportionately affect patients with
severe mental illness. Any rational analysis would show that these patients did
not have enough treatment resources before the new rationing initiatives. A new
approach is needed and I think that approach needs to be psychiatrists
redesigning the system. That needs to happen through the MPS because we have
psychiatrists with the knowledge and focus to accomplish this task. Rather than
endorse a rationed and blended version designed by people who are not providing
the care, psychiatrists need to articulate a clear statement of what public
mental health should be like in the state of Minnesota.
George Dawson, MD, DFAPA
