Executive Order: No Psychiatrists On Governor's Task Force On Mental Health

I received an e-mail two days ago from the current President of the Minnesota Psychiatric Society on the formation of a Governor's Task Force On Mental Health.  That e-mail commented that no psychiatrists were considered for the Task Force, but that psychiatrists could apply as concerned citizens and were encouraged to do so.  I have done this in the past and been ignored so I was not eager to repeat that again.

The public mental health system in Minnesota has been seriously mismanaged and ignored for the past 30 years or about as long as I have been a psychiatrist in this state.  During that time, I have witnessed a long string of bureaucrats with no specific experience trying to manage a state hospital system or more likely trying to shut it down.  Those efforts were seriously compromised by some of the same legislators who decided to develop a system of civil commitment for sex offenders because they thought it would be easier to detain them on a dangerousness standard than the usual legal criteria.  Let's forget about the commitment standard that suggests the person should have a treatable illness.  The efforts to shut down the state hospital system were also compromised by the fact that the system really started to backfire when the number of available beds in Minnesota dropped to the lowest number in the US.  At that point there was always a large pool of unstable patients circulating between the emergency department, brief inpatient stays where not much happened, and the street.  During that time significant housing resources for both adults and children with significant psychiatric problems was shut down.

The icing on the cake from the State Legislature was their myopic approach to the problem of the mentally ill being incarcerated.  They "solved" the problem by coming up with a rule that any county jail inmate could be transferred to Anoka Metro Regional Treatment Center (AMRTC) within 48 hours.  AMRTC was supposed to the the remaining flagship public psychiatric hospital for patients with no forensic problems, that is they had not committed a violent crime due to mental illness.  This was a predictable double whammy, sending violent inmates to a hospital setting and short circuiting long waiting lists of patients waiting to get to AMRTC as a result of commitments at community hospitals.  This has led to a record number of assaults on staff working at AMRTC, at a time when nurse manager staff critical in managing aggression had been downsized.

Community mental health centers (CMHCS) have certainly not fared any better.  At some point the decision was made that they could be treated like managed care clinics.  In other words they would be funded by staff "productivity" and practice medication rather than psychotherapy focused services.  Even then, reimbursement from traditional funding sources was so poor or so entangled in unnecessary paperwork that the funding was inadequate to keep the doors open.  Some CMHCs have just gone out of business and advised their patients to see primary care physicians or distant mental health clinics.  People generally do not drive long distances to be seen, at least not for very long.  It is hard enough to drive across town, much less several hours for an appointment.

Looking at the goals of the Mental Health Task force and who the Governor wants on it - it is clear that this is a serious committee with a serious mandate to develop a continuum of care and the supporting infrastructure with funding sources.  The political and managerial members of the Task Force are carefully specified.   Why then would representatives of the same failed agencies from the past be appointed to serve on it?  Why are there no psychiatrists or psychiatric nurses - linchpins of what can be loosely described as this system of care?  Why are there no psychiatric social workers - the people with the most experience in dealing with the glaring lack of resources?  These are the people who know what the problems are, how they can be solved, and what they have to put up with every time a state politician or bureaucrat makes another bad decision.  And yet none of these groups are specified Task Force members.

The implicit question is how many times these state government driven processes need to fail before there is a rational process?  One of the associated questions I dealt with as the President of the Minnesota Psychiatric Society is why professional organizations in the state always seem to fall silent about these processes every time they occur.  There are psychiatrists employed in these systems that may not want to hear any criticism from their professional organization about the overall processes, and that is something I have never really understood.  There are certainly plenty of professionals who avoid contact with these systems entirely.  It is one thing to have to try to function very day at work in an environment where doing the work is impossible due to financial and bureaucratic constraints.  It should be fairly obvious that is not a personal criticism of any employee in that system.   It is well past the time when the professional organizations represented in these systems get involved and tell whatever Task Force coming down the pike what is necessary to provide quality care to people with severe mental illnesses.

Until that time comes, I encourage every psychiatrist in the state to use my standard answer about why the mentally ill in this state get rationed and inadequate treatment:

"This decisions in this state are made by people who know considerably less about it than I do."

That is just the way we do business in the USA right now.  At some point the American people were sold the idea that managers with no particular skill other than declaring themselves to be managers were what we needed to solve problems.  Being a politician or a manager seems to trump just about every technical skill, but in this case the resulting problems have been more than a little glaring.  Knowing how to treat the severe mental illnesses that are seen in state hospitals and CMHCs requires more than an MBA or JD.  You have to be well trained and know what you are doing.

This Task Force seems to be a collection of what has come to be called stakeholders and it is more than a little ironic that this group never seems to include the people who show up each day to do the work. 


George Dawson, MD, DLFAPA


Reference:

Here is the original Executive Order - dated April 27, 2016.


Supplementary 1:

A rich source of political rhetoric that is frequently used against professionals by managers is: "Let's see you come up with a solution."  They never really step aside and let the professionals manage.  They are just trying to shut them up.  Well here are a few ideas for starters that I will put up right now against any Task Force product.  And I am the only stakeholder writing this blog:

Minnesota State Hospitals Need To Be Managed to Minimize Aggression - link

Minnesota's Mental Health Crisis - The Logical Conclusion of 30 Years Of Rationing - link

Minnesota Continues A Flawed Approach To Serious Mental Illness And Aggression - link

Public Sector Mental Health Continues to Be Squeezed Out Of Business - link







 

How The Ruling Class Impacts Your Health Care and Why They Need To Be Stopped

The truth crops up in unexpected places.  A colleague directed me to an article is USA Today that I found to be very interesting.  It clearly describes the central problem with health care in America.  From that article (see reference for full text, clinic map and video):

"This is the crux of the whole thing," said Wanda Kuehr, a psychologist who agreed to speak out about the problems after retiring Feb. 2 as the program's director of clinical services. Non-medical managers want to "get the reports in on time and fill the slots. They think that makes a good program. Our goal is to give treatment to soldiers. And (the bosses) see that as inconsequential ... What's happening to soldiers matters and the Army can't just keep pushing things under the rug."

The report details what happened when the Army's outpatient substance use clinics were shifted from medical oversight by the Surgeon General's Office to the Installation Management Command.  This change occurred in 2010.  Some of the changes noted are striking including a basic error in hiring an unlicensed counselor.  Since 2010,  90 soldiers committed suicide and 31 of those suicides occurred after reviewers concluded that there was substandard care.   They could not conclude that the substandard care was causal.  Review of additional data showed that 7,000 soldiers were identified as having a problem but not offered treatment.   Half of the 54 substance use clinics were rated as substandard, specialists identified "poor continuity of care" as a problem, and staff attrition as a significant problem.  Only 309 of 352 counseling positions are currently filled.  The same article estimates that 104,000 soldiers have drinking problems.

What is the significance of this report?  I don't think there is anything unique about what happened to the Army's substance use clinics when the management changed.  It has been happening everywhere else for at least 25-30 years.  Before that time, medicine and specialty departments were managed by senior clinicians based on merit.  The department heads were active clinically and they were valued for their clinical and research expertise.  Some of the most valuable teaching experiences I had during my training occurred due to direct contact with these department heads.  Reviewing brain and spinal imaging with the head of the Neurosurgery Department.  Doing rounds at night with the head of the Renal Medicine Department.  The list goes on.  The point is that all of these experts were engaged in treating patients and teaching medical students and residents.  They had an intimate connection with the provision of care and the profession.  Many of them also had great personalities.  So what changed?

They changes were subtle at first.  When the managers took over they decided to replace some of the department heads at the periphery.  Suddenly there was no longer a certain department that people counted on and their duties were subsumed by another department.  The dislocated clinicians either quit in frustration or were relegated to a more peripheral role in the clinic or hospital.  They could no longer support a teaching mission and suddenly that block of knowledge was no longer available to students.  These experts were consulted in complicated cases to back up the generalists who were now seeing their patients.  The next step by the managers was to suggest that productivity in the larger departments was uneven.  They suggested that they had a metric so that would assure that everyone in the department was pulling their weight.  When I first heard that explanation, I looked around and concluded it was a myth.  Everyone in my department was a hard worker and that was borne out by the actual numbers.  The numbers were the real story.  The rhetoric had allowed the managers to introduce a system to manage productivity that was completely subjective.  But that was all the managers needed to develop a system to manage knowledge workers like production workers even to this day.

Why would anyone want to be a manager?  Well it seems like easy work if you can get it.  Instead of dealing with complex problems that require you stay current in a certain body of knowledge, interact with people in an ethical way, and have extremely high levels of accountability why not just manage numbers and tell people what  to do - especially people who are as politically inept as physicians and their professional organizations.  If I ask physicians that question, I usually hear that being a manager or studying business would just be "too boring."  That may be applying a medical metric to business that could be far from the mind of managers.  Some business educators and critics have pointed out that over the past 2 decades, there is evidence that managers have developed who are focused on short term results and in some cases "the pursuit of short-term shareholder interest, as well as naked self-interest on the part of managers, into managerial virtues." (reference 2).  Instead of a manager who knew and was promoted from within the business and who had a vested interest in the quality of the services and interests of the employees, we now have a class of managers who are mobile, highly paid, and have no particular expertise in the affected business.  Piketty notes that the United States has invented a "hypermeritocratic society" of "supermanagers".  These supermanagers are typically executives of large firms who have been able to obtain "historically high, unprecedented compensation packages for their labor."  He also concludes that "the vast majority (60-70%) of the top 0.1 percent of the income hierarchy in 2000-2010 consists of top managers."(p. 302).  I don't know Piketty well enough to say what his conclusions about why this meritocracy exists.  He does point out that it is twice as likely to occur in the financial services industry.

There are interesting parallels in the management of financial services and medicine.  In both cases, the managing class came about largely as an invention of federal and state governments.  The invention of the manager's tools in medicine (billing and coding, utilization management, prior authorization, managed care) parallels the development of credit reporting and the ability of financial manager to put your savings and retirement funds at risk all of the time without offering you any compensation for the use of your money.  Both of these systems are subsidized by huge hidden tax subsidies from American taxpayers.

When I try to talk with people about this problem their eyes glaze over.  Advantage to both the financial and business managers.

In the meantime, when you drive by your local hospital and it claims to be one of the "Top Hospitals in the US" - don't be surprised to learn that there are at least 600 hospitals on that list.              


George Dawson, MD, DFAPA


1:  Greg Zoroya.  Investigation: Army substance-abuse program in disarray.  USA Today.   March 12, 2014.

2:  Rakesh Kurana.  MBAs Gone Wild.  The American Interest.  July 1, 2009.

3:  Thomas Piketty.  Capital in the Twenty-First Century.  The Belknap Press of Harvard University Press.  Cambridge,  Massachusetts 2014.