Policy Makers Are Always The Weakest Link In Healthcare

When it comes to solutions to the opioid epidemic - talk is cheap. The last 20 years everybody has “the solution”. The AMA came up with a new version of theirs entitled “AMA Opioid Task Force Recommendations for Policymakers.”  Inspection of this page shows that it is basically a rehash of everything we have known over the past 10 years or longer. The only new message is that the AMA is now suggesting that policymakers should follow these recommendations. In this era of patient empowerment, direct advice to patients is completely missing.

Drug legalization advocates have apparently vilified the Reagan era “Just Say No” campaign to the point that attempts at primary prevention of substance use are now politically incorrect and forbidden. How can you possibly stop opioid and methamphetamine epidemics when there is a large and vocal advocacy for legalizing all drugs emboldened by the cannabis campaign? There are few reasonable voices out there saying “You know you can really live a better life without drugs or alcohol”.

It should probably come as no surprise that real action on the drug epidemic cannot be expected from a government that is unable to end a decades long streak of mass shootings. We hear the familiar refrain that people were “in the wrong place at the wrong time” or that they are “fallen heroes” and that “now is the time to move on”. A real adaptive response to mass shooting like even slightly tougher gun laws would make a difference. Despite hearing that “this is the last time that our children can be victimized” the mass shooting saga drags on - courtesy of local and federal governments.

The resolution of the opioid epidemic is another example of how our government doesn’t work on serious public health issues.  The epidemic has been in place for the past 20 years.  Using deaths by overdose as a proxy measure suggests that things may be improving the last couple of years, but the epidemic is far from resolved.  The more recent problem has been that people who started using prescription opioids have changed to heroin or fentanyl – the supplies of both are plentiful and less expensive than the street value of typically prescribed opioid pain tablets.

A few words about the points the AMA has in their graphic:

1. MAT - medication assisted treatment for opioid use disorder is considered a major advance in treatment. That applies both to methadone maintenance treatment and more recently buprenorphine maintenance with various preparations. Sustained-release naltrexone injections are also an option but they are more controversial due to the longer induction and wait time until the patient is safely covered by opioid receptor antagonism. The current AMA position is to remove prior authorization from these treatments so that they are more readily available. Some treatments are more cost-effective than others. It is not clear from the statement how the AMA hopes to remove these barriers particularly since they have not been effective in removing them for the past 30 years of utilization management or prior authorization. They may be counting on political leverage in this case but I don’t see it happening. Regulators and politicians could easily make this an exception to the current utilization management and prior authorization statutes that they have on the books but it should be apparent from that statement that they are the problem in the first place.

2. Mental health - the document cites the well-known correlation between mental illness and substance use. The document also cites the Mental Health Parity Addiction and Equity Act (MHPAEA) as meaningful but the only way this law gets enforced is if civil action is brought against healthcare companies. These healthcare companies are protected by legislation and they basically do whatever they want. The AMA Task Force suggests that healthcare company should be “held accountable” but that hasn’t happened in the 10 years since the MHPAEA has been passed.  The document suggests that a number of addiction specialists should be in the networks of these healthcare providers, but for 20 years politicians have been rationing mental health services to the point that county jails are currently our largest psychiatric institutions. The mental health suggestion in this document seems like another wish.

3. Comprehensive pain care and rehabilitation access - I would really like to see the numbers on this one. If anything there has been a tremendous proliferation of freestanding or chains of pain clinics over the past 20 years. That proliferation correlates directly with increasing opioid prescriptions. As far as I can tell there has been no movement at all in terms of determining what constitutes a quality pain clinic versus something else. This may have to do with the politics that wrung the word “quality” out of the healthcare system 30 years ago. There is also an access problem. In other words there has always been “non-opioid alternatives” like physical therapy but healthcare systems ration their utilization.  This might be another area where education is important and convincing people that a course of physical therapy even if their healthcare company makes them pay for it is potentially more beneficial than taking opioids and getting deconditioned for a period of time.

4.  Maternal and child health - there is no doubt that punishment-based paradigms can intrude on the parental relationships with children and result in destabilization of families. This usually occurs on a county by county basis and there are no statewide standards and no specific treatment facilities. The problem is compounded by the fact that most states consider social services to be as expendable as mental health services and it takes more than a suggestion to reverse that 20-year trend.  Recently, the child protection issue as a result of substance use has become so bad that additional tax legislation is needed just to cover this problem.

5. Civil and criminal justice reforms - the most significant reform suggested in this section is that MAT is continued when a person is incarcerated and after they are released. This is a tall order considering how difficult it is for anyone to access MAT in an outpatient setting. Jails and prisons have the absolute worst record. The evidence for that is people who are acutely taken off of methadone, buprenorphine, or other psychiatric medications at the time of incarceration. That can lead to weeks of opioid withdrawal symptoms and intense physical symptoms.  Despite many county jails considering themselves to be psychiatric hospitals very few of these places are equipped to assess and treat psychiatric disorders or do medication assisted treatment of substance use disorders.

That is the AMA WishList and all of its deficiencies. I have not seen a realistic assessment of the problem and how to reverse it in spite of the fact that there are two documented opioid epidemics in the medical literature and suggestions about how they were resolved. I never heard anyone referencing them. Medication assisted treatment was one component but there are other significant factors that no one seems to be talking about at this time.

Working in a residential treatment facility provides me with unique perspective on the problem. The continuum of care ranging from residential treatment to intensive outpatient treatment to date treatment to self-help groups like Alcoholics Anonymous and Narcotics Anonymous depends on a number of factors to make it work. First and foremost is a competent staff in the facility with reasonable boundaries and a supportive environment. Most medical facilities do not have this because of significant bias against people with substance use disorders. There are some treatment facilities that have similar biases and they should not be allowed to admit people until that problem is resolved. The measures recommended by the AMA Task Force are medically weighted and that means that treatment facilities need to have medical staff. If the facility needs histories and physicals done medical staff need to provide that function as well as comprehensive detoxification, treating associated medical problems, and providing psychiatric care and MAT. There is no point in having residential or outpatient treatment programs in a network if they cannot provide that level of care. People who need MAT should not be treated in facilities where they cannot get medical assessment and treatment.

That basic fact seems to be missing from the AMA Task Force guidelines, state regulations, and any discussion at the federal level about what kind of treatment is needed for people with active opioid use disorders.

The AMA could be of more service referring people to appropriately staffed treatment programs and advising the public on the source of all of these obstacles of care. As I have been writing here for years now those obstacles are a product of pro-business government policy at both the state and federal level and how those rationing businesses are able to operate. Until that basic flaw is corrected - I do not anticipate any increase in access to treatment (at least effective treatment), increased access to appropriate social services, or sudden revision of county jails to suddenly make them functional psychiatric units.

There are some changes that would make an immediate difference in the opioid epidemic instead of the continued evidence-based platitudes.  If there are any policy makers or politicians out here that are serious about making some changes - here they are:

 1:  Hold physicians harmless for providing MAT:

The suggestion that more physicians should be providing MAT for opioid use disorder has gone from a suggestion to more of a demand.  Just this weekend there have been debates about why Emergency Department Physicians aren't providing MAT for every person with OUD that they see.  My first thought when I saw that was: "Are they serious?" People are not presenting to EDs with casual use.  They are not people coming into clinic intentionally in withdrawal to start buprenorphine induction. They are generally people with very serious use problems who end up in EDs because of a different problem. Many of them are polysubstance users with multiple drugs on board and in many cases drugs that are typically flagged as having potentially serious interactions with buprenorphine.  Add to that the dearth of buprenorphine prescribers that will accept referrals from an ED and it makes perfect sense that Emergency Medicine physicians do not want to send people out with buprenorphine.

The physicians are not the problem, the practice environment is.  The solutions seem obvious to me.  The first is to indemnify the physicians for providing care that is harm reduction to patients with high risk. This already happens in state statutes that cover Good Samaritan provisions, mandatory reporting of child and adult protection concerns, and civil commitment and guardianship proceedings that hold the petitioners harmless for good faith activity.  MAT is a very similar endeavor. But I would not just stop at a vague statutory requirement. I would tie it in with abbreviated training for MAT.  When I took that training, at least half of the patient case examples were high risk with limited resources, psychiatric comorbidity, and they were using high levels of multiple substances.  The answer in each of these scenarios was to prescribe buprenorphine as a way to assist the patient with the OUD aspect of the problem. 

2:  Open up addiction clinics:

The idea that primary care physicians are all going to start seeing large volumes of these patients will not materialize as long as there is a problem with cross coverage.  I have seen it happen many times. A well intended physician starts prescribing buprenorphine and even in a mutli-specialty clinic has nobody else to assist and is on-call 24/7 for years until they burn out.  There has to be a structure in place where there are clinics that can handle large volumes of patients including the referrals from all of the local EDs and correctional facilities and provide adequate cross coverage for the physicians prescribing buprenorphine. 

3:  Decrease the training requirement:    

Unlike others - I don't think it can be eliminated for the reason I cited above.  The physicians and other prescribers need to know the high risk scenarios that they can treat.  I think it could probably be done in two hours with a case book of treatment scenarios.  The case can be made for collaborative care/mentoring arrangements with experienced physicians, but the funding of those scenarios should be seriously considered.   

4:  Provide temporary housing programs to take people directly from the ED and crisis appointments: 

As a former acute care psychiatrist - I know the uneasy feeling of providing brief opioid detox services and discharging patients with OUD to the street with medications that have street value.  There is no surer path to immediate relapse.  If we are really serious about helping people get established on MAT, they need a stable environment where it can happen. 

5:  States need to license substance use programs only if they provide medical services and MAT:   

If we are all serious about the effects of MAT in OUD it is time to start acting like it.  There is no longer an excuse or reason for not offering MAT to all patients in residential, extended care, or outpatient treatment programs.  There are no religious or ideological grounds that justify not offering these services and the license of all treatment facilities should depend on it.

These are my ideas about stopping the opioid epidemic that stop all of the platitudes in their tracks.  There is a rational way to proceed that does not depend on physicians sacrificing to keep the irrational system afloat. The rational way will cost money, but it will also save money but not in the way politicians usually talk about healthcare savings. It will save money and resources by saving lives, not investing in inadequate treatment, and finally putting a dent in the large circulating pool of opioid and polysubstance users that are circulating between emergency departments, inpatient units, drug treatment programs without MAT, detox units, shelters, and jails.    

George Dawson, MD, DFAPA

The Reality Of Burprenorphine Therapy

It is increasingly popular for politicians and healthcare businesses to discuss their ideas about how to end the opioid epidemic that they started.  One of the common themes is widespread availability of both buprenorphine maintenance therapy and naloxone opioid antagonist therapy for acute overdoses.  I am certainly not opposed to either and in fact work in an addiction treatment environment where these are two of several medication assisted therapies used to treat addictive disorders.  I am skeptical of the idea that broad prescribing of these therapies in either primary care clinics or some treatment settings will ever occur.  Naloxone will be more readily available because there is a movement to create easy access without a prescription.  That will never happen with buprenorphine.  Last week - an article in JAMA backs up my skepticism (1).

The JAMA article looks at 3234 buprenorphine prescribers in the 7 states with the most buprenorphine prescribers.  In their introduction the authors talk about the policy initiatives to increase the maximum patients per prescriber from 30 to 100 patients after a year.  The average monthly patient census per month varied from 7 - 22 patients and a median monthly patient census of 13 patients.  The duration of treatment episode was 53 days.  This illustrates that the monthly census was well below the allowed limits and the duration of treatment was well below the recommended maintenance guideline of 12 months.  They cite evidence that novice prescribers wanted more access to substance use counselors or other prescribers with more experience as potential limiting factors.

The authors of this article do not offer other explanations for the low rate of buprenorphine prescribing.  I have a few.  I really do not like stigma arguments.  To me stigma seems like an excuse for not being able to overcome societal biases toward a particular problem.  I don't see how you can train to be a physician and not have most of these biases wrung out of you.  With addictions and mental illnesses there may be a stronger bias based on personal experience.  Some physicians may have come from a family where the the father was an alcoholic or a heroin addict living homeless on the street and everybody was used to that idea.  Some physicians may have come from families where the father was still drinking and dying of cirrhosis and the familiy opinion was that he "has a right to drink himself to death" rather than get treatment that he did not want in order to stop drinking.  Other physicians may have come from families where father and his father both had severe alcoholism.  Grandfather drank himself to death by the time he was 50.  Father got treatment for his alcohol problem and was in stable recovery for years.  All of these personal experiences and the reactions to them will affect how a physician approaches alcoholism and addiction.

Those biases are all part the the inevitable decision-making process that leads physicians down specific career paths.  I have lost count of the number of times that another specialist told me that they really liked psychiatry and were considering the residency except for certain features of the field.  A couple of examples include needing to try to predict suicide and aggression and live with the consequences or dealing with a certain diagnostic group like patients with severe personality disorders.  People are less specific about addictions, probably because as medical students and interns we all see the severe effects.  Most of the acute care hospitals where physicians train have 30-50% of their admissions based on the acute effects of alcohol or drug use.  That includes many admissions for acute hepatitis, hepatic encephalopathy from cirrhosis, acute alcohol poisoning, acute overdoses on addictive drugs, and various psychiatric morbidities like delirium and psychosis from the acute effects of addictive drugs.  It is less obvious but addictive drugs and alcohol are also overrepresented as reasons for admission to surgical trauma units and burn units.  Most interns and residents see these effects first hand and develop both short term and long term perspectives on these problems.

This seems like another case of managers and politicians not appreciating the intense interpersonal aspects of medicine.  Physicians are all not foot soldiers just waiting for the next assignment from a policy maker.  Physicians have probably carefully selected the type of practice they want to be in and there are more than the technical aspects of the speciality that were considered.  It takes a unique skill set to treat people with addictions.  Treating and maintaining an opioid addict in treatment long enough with buprenorphine maintenance for them to realize any benefit is a very unique skill.  Being affiliated with other buprenorphine prescribers is also a necessity to provide cross coverage for patients.  Speciality care centers for addiction seem like an idea to me that does not get a lot of consideration.  Trying to run a buprenorphine maintenance program in a practice environment that is rationed to the degree it currently is does not seem feasible to me.  Adding buprenorphine maintenance as just another task for a busy primary care physician practicing primary care medicine is not likely to work.  It should be obvious that these physicians have  more than enough to do right now.

There is a lot more to it than increasing the maximum numbers of opioid addicted patients on buprenorphine maintenance and trying to treat as many people as possible.  The data from this paper illustrates that.  There is also the issue of the preventing the pool of opioid users from increasing while trying to treat those who are currently dependent on these drugs.  That seems like the best long term option to me.

Addressing this complicated problem takes more than a licensed buprenorphine prescribing physician sitting behind a desk who is willing to prescribe it.  It takes better infrastructure including managers who are enlightened enough to get that physician the kind of resources they need to do the work.  I never hear politicians or policymakers talking about that.


George Dawson, MD, DFAPA


Reference:

1: Stein BD, Sorbero M, Dick AW, Pacula RL, Burns RM, Gordon AJ. Physician Capacity to Treat Opioid Use Disorder With Buprenorphine-Assisted Treatment. JAMA. 2016 Sep 20;316(11):1211-1212. doi: 10.1001/jama.2016.10542. PubMed PMID: 27654608.


        

The Demise of the "5th Vital Sign"

The American Medical Association came out two days ago and said that they were dropping the pain as the fifth vital sign movement because it encouraged opioid overprescribing.  Even more interesting is that I did not get the news from the AMA (I am a 30 year member) but from the Pain News Network.  The only stories that I could Google the next day was about the AMA defending its position against attacks from pain societies and organizations who want to maintain what I would describe as a liberal approach to opioid prescribing as the best way to approach pain.  My term liberal is meant to connote a political position with no basis in science and the lack of science started in 1998 with the pain as a 5th vital sign approach.  In 1996, the President of the American Pain Society declared pain as the Fifth Vital Sign.  In the year 2000, the Joint Commission (then JCAHO) launched a pain initiative that described the 10 point pain scale as a "quantitative approach to pain."

I don't know if quantitative analysis is still a prerequisite for medical school, but this is a reason why it still should be.  In quantitative analysis, the task is to measure chemical concentrations accurately and reproducibly.  To use a quote from my old analytical chemistry text (1): "Qualitative analysis is concerned with what is present, quantitative analysis with how much is present."  The ability to do this is often a major part of the grade for that course.  Since the chemical composition in the samples are known - they should be determinable with precision.  In some cases, a lack of accuracy can reflect problems with the analytical technique if there are widespread variations in the results.  This is a true quantitative approach.  Asking a person to rate their pain on a 10-point scale is not.  Pain is a subjective experience influenced by a number of variables including whether the pain is acute or chronic, emotional state, the presence of an addiction, and personal biology affecting pain perception.  It is not a quantitative assessment.  It is as obvious as asking someone where they are on the 10-point  scale and being told they are a "14".  There are a lot of potential messages with that statement, but none of them involve an accurate measurement of pain.  A quantitative scale has no implicit meaning - it is supposed to be a known measurable quantity no matter what.

From a medical perspective, there is also no better example of the adverse consequences of widespread screening for a problem.  Chronic pain varies with age and other demographic factors.  Epidemiological surveys show widely variable numbers of people with chronic pain, but some suggest an average is about 25% of the population and 10% of the population with pain that has some secondary disability.  While there are no good ways to estimate the optimal amount of opioid needed to treat pain in a population, current data suggests that the US is the largest consumer of prescription opioid drugs in the world.  For example, the US has 5% of the world's population and Americans use 55% of the world's supply morphine and 37% of the world supply of fentanyl.  By contrast 80% of the world population uses 9.9% of the morphine and 19.7% of the world's fentanyl.    The United States is clearly at the top in terms of opioid consumption.

Clinical trials have also shown that opioids are moderately effective for some forms of chronic pain and no more effective than non-opioid medications.  The screening approach to chronic pain is clearly associated with overexposure to opioids, widespread availability of illicit sources of opioids, and an epidemic of overdose deaths.  The idea that rapid assessments can be made with rapid qualitative screening by anyone also eliminated pain specialists as gatekeepers in the decisions about who would receive treatment with opioids for chronic noncancer pain.

In the opening days since the AMA statement, it appears that political forces are lining up to maintain the status quo.  The idea that the AMA has to defend their position seems like pure rhetoric to me.  How about the American Pain Society defending the original statement in the context of everything that has happened since?  Despite defensive statements about how opioid prescribing was increasing before the position was adopted - the hard data suggests that it was associated with a major inflection point in opioid consumption in the USA.

The policy debate on this simple statement has far reaching effects for health policy in the United States.  At every level in today's health care system there are groups of managers/administrators who have set themselves up to monitor various measurements and hold somebody accountable.  I doubt that they know the difference between quantitative or qualitative measurements any more than the people who proposed that a subjective pain scale was somehow a quantitative measure.

I doubt that any one of them ever took a class in Quantitative Analytical Chemistry.



George Dawson, MD, DFAPA



References:

1:  James S. Fritz and George H. Schenk.  Quantitative Analytical Chemistry. Second Edition.  Copyright 1969 by Allyn and Bacon, Boston, p 3.



Attribution:

Pain scale graphic downloaded from Shutterstock per their standard license on June 29. 2016.

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.