Welcome To 1974

A colleague forwarded me a link to a newspaper article today about the latest Twin Cities managed care innovations for treating people with severe mental illnesses.  It had nothing to do with managed care companies trying to save money or avoid penalties.  Like most of these stories in the press there is a heavy human interest focus.  The treatment details are given of a man with schizophrenia and depression who is benefitting "from a fundamental shift in the way hospitals and health plans treat people with severe mental illnesses."  The author goes on to explain how social services including housing, transportation, and job training are being implemented prior to discharge and coordinated by social workers.   The article suggests that the reasons for this are two fold - to prevent the "revolving door" of readmissions to the hospital and a new Medicare penalty for readmissions during the first  30 days of discharge from a hospital.  The programs at a number of Twin cities hospitals are described.  The Minnesota law requiring admission to a psychiatric hospital from a jail within 48 hours of commitment is also cited as a complicating factor in the large group of patients that have no stable housing, no medical or psychiatric care, substance use problems and who continue to rotate in and out of psychiatric hospitals.  One of the managed care administrators describes it as a "sea change".

It turns out the "sea change" occurred in 1974.  It occurred in Wisconsin and not Minnesota.  That was the year that Len Stein, MD and a group of dedicated clinicians came up with the idea that patient with severe mental illnesses could be maintained outside of hospitals as long as they were provided with appropriate housing, support, and in some cases vocational services.  I know because I trained under Dr. Stein.  He was a personal supervisor and I did a training rotation at the Dane County Mental Health Center.  I can still remember the slide from his community psychiatry presentation that showed the overcrowded conditions at the state hospital - one of the reasons behind the community psychiatry movement.  My training occurred about a decade later and at that time there were three  different models of care that all involved community support.  The most well-known of those models is Assertive Community Treatment or ACT.   I was well versed in these models and providing the necessary care and for the first three years out of training I was the medical director at a community mental health center and spent have of my time working with the community support team.  That team provided crisis services and support on a 24/7 basis to patients with severe mental illnesses.  That was 30 years ago.

After the community mental health center,  I moved to the Twin Cities where I spent the next 23 years working in a metropolitan hospital primarily running an inpatient unit.  My focus for the first 10 years was trying to get people interested in community support services for patient we were discharging to the community.  At first, there was a patchwork of public health nursing and large housing units  with nursing supervision for our discharged patients.  But eventually there was nothing.  I was told point blank by various administrators that they really were not interested in hearing how things worked in Wisconsin.  They did things differently in Minnesota.  When I could no longer ask public health nurses to check on discharged patients - there was no help for them at all, except for an appointment to see a psychiatrist if they did not forget it.

That changed slightly when the state decided to shut down state hospital bed capacity and one of the psychiatrists there was able to get funding for ACT teams.  The rationale by the state was that some of the money to maintain state hospital beds would be diverted to the ACT teams.  Eventually that initiative increased but there was still not enough capacity.  There was still a large patient population without adequate housing or assistance.  The economic plight of many of these people was worsened by "spend down" provisions implemented by the state.  That meant that even though their income was 100% disability payments, they could be expected to pay up to 60% of it for medications.  That typically meant that the person went from poverty status to worse in order to continue recommended medications for their psychiatric disability.

Another problem was the bed situation and approaches that were being used to manage those beds.   That last half of my inpatient career, there was a continuous large pool of patients flooding Twin Cities emergency departments.  That resulted in initiatives to admit and discharge as soon as possible.  The entire focus of admissions and discharges was on "imminent dangerousness" even though there is no such legal standard.  It was a business standard of care.  Many people seeking admission because they were miserable realized this and said they were suicidal in order to get admitted.  Conversely, many people who still had significant problems and no good way to resolve them were discharge because they no longer met the "imminent dangerousness" criteria.  There were no quality approaches to care only a focus on rapid discharges of very ill people.

So I have to shake my head when I read about the "new" approach to treating mental illness and helping people to maintain themselves in the community.  There is really nothing here that was not done in Wisconsin nearly 40 years ago.  In the meantime there is a severely deteriorated infrastructure with fewer beds in both designated hospitals but also supportive housing.  I have significant doubts about the funding of these services since we know that managed care companies don't do community support services.  Who is paying for these social workers and psychologists?  Will they have to submit billing documents that are not practical to complete?  Even if they are being paid for by the state, that doesn't necessarily guarantee future funding.   At one point all of the public health nurses I was working with in the 1980s were told they could no longer see patients with psychiatric problems.  And what about the continued rationing by managed care companies now being made to look like it is innovation?

Welcome to 1974.

George Dawson, MD, DFAPA

Chris Serres.  Strategies shift for treating mental illnesses.  Star Tribune January 19, 2016.

The Model of Psychiatric Care for the Future

The Psychiatric News came out with an article yesterday that is critically important for all psychiatrists to read.  It reveals the American Psychiatric Association (APA) thinking about the future role of psychiatrists and the model of care that they are promoting.  The diagram in this article titled "Integrated Care Relies on Team Approach, Consultant Role for Psychiatrists" is a critical read because it shows what is basically a managed care paradigm for marginalizing psychiatrists.  There is is a "BHP/Care Manager" between the psychiatrist and the patient.  This is a popular managed care approach to having "care/case managers" making discharge decisions for psychiatrists providing inpatient care.  For anyone with professional expertise and direct responsibility to patients it is unacceptable.  

The main reason that psychiatry has been marginalized is that all of the knowledge in the membership about what we do and the value we add is ignored in the face of special interest research.  The research that forms the "evidence base" for our marginalization in the Psych News article is a good example.  There is a long history of similar studies have been published to sell the managed care industry.  I can come up with a pharmacoepidemiology study from 20 years ago that show that putting everyone in a primary care clinic on fluoxetine saves money on as many parameters as this article claims for integrated care.  Instead of confronting that and saying: "You know psychiatrists do a lot more than that" - the APA seems to accept it and think  that integrated care is some big deal.   From the diagram it is clear to me that integrated care is just the latest head of the managed care hydra.

The other aspect of the article is the omnipresent "cost savings" rhetoric.  Professional organizations have bought this hook line and sinker and seem obliged to include that nonsense in policy about the future of their speciality.  The difference of course is that in the last two decades, Cardiology has built out a trillion dollar infrastructure being "cost effective" and we are now treating people in jails who should be in psychiatric hospitals, we have few functional detox facilities and have minimal resources to help disabled patients in the community.

What we need here is a reality based characterization of what psychiatrists do and on average it is a lot more than sitting in a primary care clinic and advising primary care docs about what to do if they can't get their depression ratings (PHQ-9 scores) headed in the right direction.  Its is just a matter of time before everybody who thinks they can make a psychiatric diagnosis by reading the DSM will think they can treat depression by reading an algorithm and psychiatry slips off the next managed care diagram.  Nobody will realize they just eliminated not just a psychiatrist but the person in the clinic who knew the most Neurology as well.

If we are going to promote any image of ourselves and an image that current trainees can be excited about, it should be a larger than life psychiatric multispeciality clinic and a group of psychiatrists who can cover the gamut of care.  That is consistent with the psychiatrist of the future that Thomas Insel, MD has talked about, and it takes a page from some of our specialist colleagues like Radiologists and Anesthesiologists.

They realized a long time ago that you are not going to get a fair deal bartering away your expertise for the sake of doing business.

George Dawson, MD. DFAPA

Mark Moran.  Report on Health Care Reform Focuses on Psychiatrists' Role.  Psychiatric News May 3, 2013.

Confusion about Capitation versus Fee-For-Service versus National Health Care

This is from the Shrink Rap blog this morning the consensus is that capitated care is better than fee-for-service care.  What is wrong with that picture?

Starting out with the much maligned fee-for-service (FFS) -  most medical and psychiatric services are not delivered in that context.  You can safely say that FFS, disappeared a long time ago.  According to a 2012 Medscape survey of 24,216 physicians across 25 specialties only 4% worked in cash only or concierge style practices. That means that everyone else is subject to varying degrees of insurance company discounting.  From my years of providing inpatient care for example,  there is a standard DRG payment based on a global discharge or admission diagnosis.  For the most common psychosis DRGs the standard payment is $4,500 no matter how long a person is stays in the hospital.

The same thing happens on the outpatient side.  I have discussed this more extensively is a previous post.  Looking at the commonest outpatient billing code - actual reimbursement for providing services can be as little as $22.45 per visit.  In the case where bills are submitted with CPT codes (common to all of medicine) Medicare pays 50% of the usual and customary charge for psychiatry compared with 80% for the rest of Medicine.  A lot depends on contracting arrangements since a contract can limit a psychiatrist to billing only a 90862 code and the company can also decide that they disagree that services were provided and either deny payment or demand repayment of a significant amount of money based on a review of the documentation.

The business adaptation to this on the hospital and managed care side (if they own the hospital) is to hire case managers to get patients out of the hospital within 3 or 4 days.  Some of these systems have confabulated their own "guidelines" that allow them to do this that are totally independent of any professional standards.  So if you are a managed care business and you own the hospital you are winning at two levels - you already shift the risk to the providers and hospitals by the Medicare style DRG payment and you do it a second time by insisting that they go along with the business decision to discharge the patient from the hospital.

Strictly speaking, the examples of discounted fees are technically not capitation.  Discounted fees still allow for some elasticity within the system because there is still a fee paid per service event.  Capitated systems of care like behavioral health carve outs can be set up to pay a set fee for managing a specific population.  For example, a system of care is under contract for providing all services to a specific group of employees for a rate that is negotiated irrespective of actual patient visits.

The best way to understand capitated care is that it is designed to provide insurance companies a significant financial incentive for rationing care.  That incentive comes directly out of the total amount of money available for health care spending   Psychiatry, mental health, and addiction services were the easiest targets due to insitutionalized stigma, lack of a vocal constituency, and the political ineptness of psychiatrists.  It is anybody's guess about how much a managed care company can make for denying or rationing care but some estimates of the margins have been as high as 20-40%.

One thing is for certain.  Capitated care is not a comprehensive national health system.  It takes hundreds of billions of dollars out of the health care system and diverts it to CEOs and stockholders.  Contrary to the political opinion it does not contain the cost of health care inflation.  One of the readers of the Shrink Rap blog pointed out that in a national system of health care you might be able to get an expensive medication like aripiprazole but you would have to wait longer.  In our current system of capitated care if your managed care company decides - you will not be able to get it at all.

That is probably the best example of the difference.

George Dawson, MD, DFAPA

What replaces DSM5? Whither RDoC?

"However, in antedating contemporary neuroscience research the current diagnostic system is not informed by recent breakthroughs in genetics; and molecular, cellular, and systems neuroscience. Indeed it would have been surprising if the clusters of complex behaviors identified clinically were to map on a one-to-one basis onto specific genes or neurobiological systems." NIMH 2011.



With the thorough politicization of the DSM5 and the dichotomous debates in the media it is surprising that nobody talked about what is in the works to replace it at the largest government funded think tank - The National Institute of Mental Health (NIMH). The proposed solutions in the media were generally to do nothing or to let a wide variety of professionals have input into criteria that have essentially been static for the past 30 years.  There was very little comment about how the DSM5 is not a very good framework for incorporating recent scientific discoveries from brain imaging, molecular biology and genomics in addition to the typical subjective descriptions of each disorder.  That is where NIMH's Research Domain Criteria (RDoC) come in.

Looking at the "Draft Research Domain Criteria Matrix" - it is hard to envision a standard 60 (or usually 30) minute clinical interview as a starting point for diagnosis or treatment.   For example, with an initial episode of psychosis, there will probably be a lot more work done trying to identify cognitive endophenotypes or other transitional phenotypes within the current subjectively derived domains.  A very conservative estimate suggests that this alone will take take least one hour of testing.  There will probably need to be a lot of time and effort expended on determining when a person is testable.  An RDoC diagnosis will be both time and resource intensive.  It won't be a template or a checklist.

I am sure that the antipsychiatry/myth of mental illness crowd and some of the thinly veiled variants of this philosophy will be disappointed.  After all,  this is a diagnostic approach that directly assails one of the most typical arguments from them: "There is no "test" for mental illness."  When the RDoC comes to fruition there will not just be one test.  There will be many tests.

Like most things psychiatric, the biggest threat to the realization of a more comprehensive diagnostic system for our most complex illnesses is not the obvious detractors.  It is the current political culture that applies junk science to the management of the health care system.  It remains an incredible fact that political ideology and not medical science dictates medical treatment in this country.  The current political consensus is that psychiatric care (like medical care) can be managed for both cost and quality by companies who can profit by rationing care.  The care they ration the most is for the treatment of mental illnesses and addictions.

Will an Accountable Care Organization (ACO) in the future spend what it necessary to thoroughly evaluate an initial episode of psychosis if it takes as many or more resources than Cardiology  currently uses to assess heart disease?  The answer to that lies in whether the stigma against mental illness and addictions in health care and governing organizations can be overcome.  Despite all of the lip service - it is that stigma that supports the current system of care that is predominately brief hospitalizations orchestrated by case managers and 15 minute "medication management" approaches to the treatment of mental illness.

You can't implement an RDoC in that environment.

George Dawson, MD, DFAPA

Concentration of Effort, Academics, and Managed Care

I follow the Nephron Power blog because I have maintained a life long interest in Nephrology or at least since I found out what it was in Medical School.  The conventional wisdom at the time was "Oh you're going into psychiatry - take as many medicine electives as possible because you will never have the chance to do medicine again."  If there are any medical students reading this - I ended up doing another 22 years of following renal function, treating people who were delirious and in renal failure, treating manic patients who were in renal failure waiting for a kidney transplant, and consulting with Nephrologists.  I  can say without a doubt that the Nephrologists who I worked with are some of the brightest, most thoughtful and hardest working people I have ever known.

I still  consider the Renal Service where I worked in medical school to be the model for academic medicine and how to teach medical students and residents.  It was located in two adjacent hospitals and headed up by a cranky old guy.  I say "old" realizing that he was probably about the same age that I am right now and he had the appearance of being cranky like a lot of old guys can get.  You could tell he was very bright, very interested and not above giving the medical students a hard time.  He made sure that on all of the consults we had conducted the appropriate "liquid biopsy" by performing our own urinalyses on patients we were seeing.

We rounded three times a day seeing all of the hospitalized patients in the morning, clinic patients in the afternoon, and hospital consults in the evening and at night.  My last action as a medical student was staffing two Renal Medicine consults at about 8PM the night before I graduated.  The other team members included another two attendings, two fellows, three Internal Medicine residents, and another medical student.  The physical layout of the service was two hospital wings and a very busy clinic with a separate day for a Hypertension clinic.  The hospital service was in the same hospital as the transplant team and we would also care for patients with transplant complications.

The  atmosphere on this service was electric.  Everyone was on time, interested, bright, academic and effective.  To this day - I consider this team from the 1980s to be the prototype for what a teaching service in a Medical School should be and in many ways how serious medicine should be provided.  When I left the hospital that night after the last two consults staffings of my medical student career I can remember thinking - should I have gone into medicine and become a nephrologist?  My fantasy in psychiatry became to recreate this model or at least parts of it in psychiatry.

Flash forward 26 years.  Most people would be fairly surprised to find out that you can come close to my fantasy in very few psychiatric units.  The patient flow into and out of many psychiatric units generally does not depend on academic considerations like providing the best medical and psychiatric care to patients.  In most cases patient flow does not depend on the judgment of psychiatrists.  My ability to care for patients with the most severe illnesses did not come about because there is an elite cadre of psychiatrists who are academically interested and have the necessary resources to provide that level of care.  It came about because the system where I worked needed a place to put these folks and I happened to be a psychiatrist who was interested in all of their problems.

I got very close to recreating at least the inpatient side of my old Renal Medicine service, but these days there are just too many administrative problems along the way.  It is impossible to take a learned approach to medicine and psychiatry with administrators breathing down your neck about an absurdly short length of stay.  It is a clash of paradigms and as far as I can tell the administrators have won.  You cannot possibly address complex problems when someone is telling you that the only reason a patients should be in the hospital is that they are "suicidal" or "homicidal" - both very loosely defined business terms for getting the patient out in time to capture about a 20% profit on the DRG payment.  Let's suspend the reality that this person is just  too ill to function or that their illness has created an impossible situation at home or they are not able to care for their new medical diagnoses until they have recovered their cognition to some extent.

If you are really interested in a rigorous approach to tough problems these days you will run afoul of a huge managed care infrastructure that is there to process patients in and out of hospitals based almost entirely on business decisions.  That makes life a lot less interesting for physicians and a lot more frustrating for patients.  Patients coming out of the managed care environment have an almost universal experience that they were hardly seen in the hospital and when they were, there was not a lot of interest in solving their problems.  They end up saying what they think people want to hear in order to be released and after they have been discharged realize that nothing has changed.

In the final analysis these are contrasting models but nobody pays much attention to the contrast.  An academic full spectrum of care model versus a severely rationed model where care is based on an administrators notion of "dangerousness".  Clinicians aware of the full spectrum of illness, grappling with all of the nuances and offering the necessary care versus a doctor sitting in an office prescribing pills as fast as they can.

That is what we are talking about and in that context - I will take the Renal Service any day.

George Dawson, MD, DFAPA