News Flash From the StarTribune - Psychiatric Patients Have "Nowhere To Go"

Not to be outdone by the local television stations, the Minneapolis StarTribune came out with their own stunning analysis of the problems with psychiatric care in the state.  At least the opening line was stunning:

"Hundreds of Minnesotans with mental health problems are languishing in hospital psychiatric units for weeks, even months, because they have nowhere to go for less intensive care, according to a comprehensive study to be released this week. " 

Notice the expertise in this sentence - we now have a comprehensive study.  We have a comprehensive study of what every inpatient psychiatrist in the state of Minnesota has known for the past 30 years!  There is a lot behind this headline that is not included in the story.  For example, they left out the part that inpatient psychiatrists and social workers are routinely scapegoated by administrators and government officials for the problem.  The system is not blamed for patients staying in the hospital too long - the doctors are.  I had the opportunity to work with outstanding social workers when I was in this setting and at some point they have to quit.  One of my social work colleagues spent all day, calling over 30 facilities to try to get the patient discharged and she failed.  She failed for two reasons.  First, the infrastructure for accepting patients with chronic psychiatric disabilities has been rationed out of existence by state and county officials.  Second, the existing facilities do not want to accept people with psychiatric problems especially if they have had a history of aggression or suicidal behavior.  The next sentence makes even less sense:

"As a result, private hospitals are absorbing millions of dollars in unreimbursed costs, while patients who are well enough to be released are being deprived more appropriate care at a fraction of the cost."

The author here clearly does not know how state and county officials think.  There is an assumption that they want cost effective and appropriate care.  In my 23 years on an inpatient unit - there is no evidence that those motivations exist.   To any career long student of the system, it should be abundantly clear that all of these administrators and bureaucrats want free care.   Only the Orwellian rhetoric of managed care could spin free care into appropriate care.  I will elaborate on free care instead - how does that happen?  It basically happens in four ways:

1.  The patient is admitted to a psychiatric unit and is too disabled to be discharged to either the street, an apartment, or their original living situation .  The hospital needs to get the patient out in 6 days or less in order to make a profit on the limited payment they get for admissions or discharges (a DRG payment).  The patient is stranded for much longer.  The patient's care is essentially free at that point.  Not only that but if the county rations placement options - they don't spend any money on placements.

2.  The patient is admitted and ends up on a probate court hold or a civil commitment.  In this case they can be stranded for months waiting to get to a state hospital.  Insurance companies and the state do not pay for people in this situation.  The care again is for free.  

3.  Homeless psychiatric patients circulate in an out of the emergency department.  They come in because they are in distress.  They know that they need to verbalize serious problems in order to get admitted.  If not they are discharged back to the street only to appear in the emergency department at a later date.  There is a large circulating population of these patients who may get briefly admitted but never get stabilized.  Apart from the nominal emergency department fee - their care is free.  But of course they are really getting no care.  

4.  Up to 2/3 of people with substance use problems have psychiatric disorders.  Many of them will show up in the emergency department with various levels of symptomatology.  If they are intoxicated they will be sent to county detox facilities - where once again the care is free but it is not psychiatric care.  

These are well hidden secrets of modern psychiatric care.  First, psychiatrists have nothing to do with how the system is managed.  Second, the myth that care is expensive.  People would always ask me if they were being charged a mythical "$1,000/day" fee to be on a mental health unit.  I can assure anyone that when all of the discounts and free care is rolled into the meager reimbursement from insurance companies, the actual reimbursement is more like hotel rates without the hotel accommodations.

The article also discusses the differences between general medical surgical care and psychiatric care. The question is asked if cancer patients were stranded and could not get to tertiary cancer care - would it be as acceptable as the case for psychiatric care?  That question minimizes the scope of the problem.  The problem with the "bottlenecks" described in the article is that they are all a result of rationing of psychiatric services.  There is nobody rationing cardiology or oncology services.  Any middle aged person who goes into an emergency department with chest pain will get state of the art care for chest pain and have all of the necessary testing.  There are no similar services available for psychiatric illnesses.  As soon as a person is admitted the current goal is to get them stabilized and discharged as soon as possible.  The resources are so meager that people frequently do not get the care that they need, because it is rationed.   The article also points out that inpatient treatment at some level is little more than containment.  With administrators rather than clinical psychiatrists running the system, there is no longer an emphasis on a therapeutic environment.  In many cases the experience is sitting around in a facility with little to do, waiting to talk with a doctor about getting released.

So - don't believe what you read in the papers.  Nothing in this article is news.  The system of psychiatric care in the state of Minnesota is dysfunctional by design.  It has been designed by managers at all levels who routinely ignore what psychiatrists have to say and who don't want to spent an additional penny on psychiatric care.

That produces deficiencies at both ends of the spectrum - the people who need to be admitted for psychiatric care as well as the people who need to be discharged.  People with mental disorders should get the same level of care as people with medical and surgical disorders.  That will never happen as long as rationing psychiatric care is justified as being "cost effective".

George Dawson, MD, DFAPA 

References:

Chris Serres.   Nowhere to go, psychiatric patients languish in Minnesota hospitals.  StarTribune August 10, 2016.

George Dawson.  News Flash From Channel 5:  "There is a shortage of psychiatrists."  Link

Supplementary 1:

Every now and then the news media comes up with a shocking story about the rationing of psychiatric services at least they are hyping it that way.   One of my favorites is on Greyhound Therapy and yes this also happens in Minnesota and probably every other state in the USA.  When it comes to rationing and denying care - nothing beats the cost of a bus ticket.

Supplementary 2:

For a look at how modern medical managers and bureaucrats running managed care organizations view psychiatric services - read this post on the Dog Quadrant.

Supplementary 3:

I posted two brief sentences and a link to this post on the page with this story on the StarTribune website.  It was deleted.  If you are reading this please direct anyone interested to this post of what is really happening with mental health and psychiatric care in the state of Minnesota and everywhere.

Crowdsourcing Psychiatric Services

I heard a very compelling story on MPR Marketplace last night about crowdsourcing.  They interviewed the founders of Gustin denim and their new method for selling blue jeans.  The old way that most of us are familiar with is to design a certain type of blue jean or brand and then market that product to the public.  That marketing consists of convincing the public why they need the product.  There are many inefficiencies associated with that model including the fact that it is very difficult to match the product with the customer and there are charges for various middlemen added along the way.  Josh Gustin and his business partner Stephen Powell decided that there was a better way.  They decided to post fabric swatches and describe what they intended to do with it in terms of fabrics and then have prospective customers support these various "campaigns".  When sufficient number of subscribers was signed up they would produce the products.  The outcome of this process is highly efficient in that there is no wasted fabric for the manufacturer and no mark up for the customer.  These essentially custom blue jeans sell for $81 wholesale and are marked up to $250 by some retailers.  That allows the wholesaler to maintain the same margins by selling at the wholesale price.  What a deal all around.

Of course the first thing I thought of was this is an ideal way to match psychiatric (or any medical) services to what the public wants.  It would be a clinic or a coalition of independent providers.  Instead of being locked in to visits determined by billing codes that don't really match very well with what patients or physicians want, the entire spectrum of services could be offered.  The pricing structure might be a little more complex if various insurances are factored in but consider the ideal case of no insurance and strictly cash payment.  There is often a lot of confusion over how long the visits last and what exactly happens in the visit.  As an example,  it is common for patients who are used to seeing a psychiatrist for 30-60 minute visits suddenly going to a different clinic and being told that they can see the doctor for only 10-20 minutes.  They have similar problems with frequency.  Even in an initial assessment, the patient may have an expectation that they have 90 minutes of history only to be told that the doctor only sees people for 40 minutes and uses the last 20 minutes for dictation.

A menu of services could be offered on an ongoing basis with a critical mass of subscribers determining any significant changes.  I would also have a menu of consult questions and conditions of varying complexities.  This would be quite an exciting approach given the state of outpatient services and how they are currently determined.  I mentioned a completely unrealistic set of billing codes as being one determinant.  Do you need to see the doctor for a "med check"?  The other is managed care and their unrealistic productivity and rationing demands.  If a person is being seen in a clinic where every doctor is allotted 10-20 minutes they may appear to be poised over a prescription pad rather than being a source of information and discussion.  Some services that would be in demand are not even offered and the justification is that they are "not medically necessary".  It should be possible to offer the rationed version of services along with a more complete version of what people may want.  I would also tend to list research proven services.  One of the main problems is that psychotherapy services are often in the mind of the therapist.  I have listed several research proven approaches on this blog.  When I talk with people who I have assessed about what I think they need, I discuss psychotherapies that have been proven to be effective for their particular problem.  The difficult part is for them to find a person providing that kind of therapy.  If should be clearly listed rather than referenced as an interest in the employee bio section of the clinic web site.

Some people (like managed care executives and the government bureaucrats who support them) will say that we cannot give patients this level of input into the design of psychiatric or medical services.  It will just not be cost effective and they will be asking for many "unnecessary" services.   In my experience talking with people over thirty years that is clearly not the case.  It turns out that most people are reasonable and make rational choices.  Some people will insist on the shortest and most cost effective approach.   Others realize that they get a lot more out of discussions than a prescription.  They find that even a 20 minute conversation about a medication is not long enough.  Some want to show up with a written list of problems for discussion and they don't want to be told that they need to set up separate 10 minute appointments for each problem.  Everyone has an expectation of service and I can't imagine that most people are currently getting it.  With crowdsourcing customer satisfaction would no longer be a joke.

Customer satisfaction would start with the design of services and their availability rather than a scripted survey designed by a managed care company to make them look good.  How else can you end up rating suboptimal, highly rationed and inaccessible services highly?  Aren't 95% of all managed care clinics and hospitals highly rated?

We are all unreasonably taxed for health care services.  It is time to let the crowd design what they want.  They are paying a very high price for it.

George Dawson, MD, DFAPA

Supplementary 1:  I hope to come up with  crowdsourced menu and post it here in the next few days.