Less Is Less - A World of Difference Between Psychiatry and Cardiology

I read Lisa Rosenbaum's opinion piece in this week's New England Journal of Medicine (1). She discusses both sides of the rationing coin. On the one hand, we don't want to reduce resources to the point that people do not get necessary care. On the other hand there are forces including financial incentives and the inability of physicians to tolerate the diagnostic uncertainty of not performing the necessary tests that lead to both increased cost and in some cases unnecessary risk to the patient. She provides an example from her personal medical history on forgoing a recommended test with no associated adverse outcome. A lot of the article is written from her perspective as a cardiologist or cardiology fellow. I can recall, the think tank studies from the 1980s suggesting that coronary artery bypass surgery was overutilized. There are many studies that suggest that medical treatment of coronary artery disease provides similar outcomes. Today we hear the same arguments about the treatment of the atrial fibrillation epidemic and the equivalence of rate control versus rhythm control. The options are presented as a coin toss to many patients. But in both cases it is much more than that. Anytime population based averages of care are applied across large populations there will be a significant number of people who do worse than the norm and may have done better with the other option. My concern has always been, the implicit pressure by healthcare companies to make money by exerting pressure in the direction of the least expensive option right up to including no care at all.

Dr. Rosenbaum discusses the "less is more" movement and the Choosing Wisely campaigns to reduce unnecessary care. She discusses the early role of the Dartmouth Atlas in pointing out the lack of correlation between cost of care and outcomes - a notion that has been discredited (2) but it was the mantra of administrators for nearly two decades.  She concludes that these movements resulted in the idea that "less care is better care or that more care is harmful."  She reviews more recent data that higher spending is associated with better outcomes. She includes recent research on unnecessary admissions and how Medicare beneficiaries discharge from the emergency departments (ED) of hospitals with the lowest admission rates were 3.4 times as likely to die with a week than similar patients admitted to hospitals with higher admission rates - even though those same patients were healthier.

She discusses overdiagnosis in cardiology. Unlike psychiatry, cardiology has a considerable array of biochemical markers, electrophysiological studies, and imaging studies that are very useful in the diagnosis and management of their patients. She illustrates the trade offs involved in considering false positives for troponin and how liberalization of the cut-off values leads to better diagnosis and treatment rather than overdiagnosis. In the area where I currently practice, the entire landscape for diagnosing and treating suspected acute coronary syndrome (ACS) has changed significantly. Nobody tries to guess if chest pain has a cardiac origin or not.  Middle-aged patients are generally admitted and tested with troponin levels and an exercise stress test the following morning if the troponins are negative. If the stress test is negative they are sent home. In most acute care metropolitan hospitals there is ample intensive care and telemetry space to accommodate all of these admissions. The cost of that overnight admission to cardiology exceeds the cost of a week long admission to an inpatient psychiatric unit with a psychosis diagnosis.

What is the parallel process on psychiatry? A patient in crisis presenting to an ED of a metro hospital in crisis has no similar guarantee of cautious screening. In the majority of cases they will never see a psychiatrist. In most cases the assessment and screening is done by nonphysicians. In addition, diagnoses and syndromes are generally secondary in the discharge process. The only way that patient gets admitted is dangerousness to self or others. That could be due to an acute intoxication, an emotional overreaction, a mood disorder, a developmental disorder, a neurodegenerative disorder, or a psychosis. The only thing that counts is the dangerousness. There are no biochemical markers or imaging markers of dangerousness. There is significant disagreement in many cases among clinicians, patients, and their families. If a person is admitted either voluntarily or on a legal hold - in any case they will typically find themselves sitting on a psychiatric unit until somebody determines that they are no longer dangerous. Hopefully they will see a psychiatrist and other skilled professionals like trained psychiatric nurses, social workers, and occupational therapists - but there is no guarantee. The issue in an acute dangerousness based psychiatric hospitalization is not a question of overdiagnosis - but whether the patient will get the correct diagnosis and an adequate medical evaluation and discharge plan.  The driving force for that is rationing. The cost of an overnight stay on a cardiology unit with telemetry, blood tests, and an exercise stress test in the morning easily exceeds the payment for complex psychiatric care. I would say that complex psychiatric care is the equivalent to treating a person with a psychosis, extreme mania, or life threatening catatonia or depression. In general we are not worried about the issue of overdiagnosis. People flee psychiatric units if they are given the opportunity and they don't really care if they get diagnosed or not. Psychiatrists cannot present them with an array of options because there aren't any.

When I saw the term overmedicalizing in Dr. Rosenbaum's title - I wondered if she was aware of its Szaszian origins? Szasz was apparently so enthralled by a form of psychiatric treatment that was totally subjective and more akin to a literary critique that he suggested society has an interest in using psychiatry as a way to exert social control over certain subgroups.   The logical conclusion is that mental illness is not a disease and calling something an illness is strictly a power play.  For some reason society and its unholy alliance with psychiatrists is seeking to exert power over a subset of society for unclear reasons. I doubt that Dr. Rosenbaum is using the Szaszian definition. She is probably referring to any number of situations where non-disease is treated as disease.

There are many problems with Szasz - not the least of which is how he would end up treating any number of severe mental conditions. More modern authors on what is and is not a disease seem confused about the imprecise definition, especially in the absence of gross pathology. There is no family member affected by schizophrenia, bipolar disorder, depression, alcoholism, or addiction that doubts for a moment that these are diseases. They generally don't doubt that psychiatrists, at least until very recently were the physicians most interested in treating these problems.

Dr. Rosenbaum's theme does not seem to apply to psychiatric practice. There are no expensive tests to overutilize. Stays on inpatient units are capped by ridiculously short lengths of stay that do not reflect the severity of illness.  Even then - admissions to psychiatric units are generally under the control of emergency physicians.  This is part of the oversimplication, that she referred to. That oversimplification characterized all inpatient stays by diagnosis related groups (DRGs) and suggested that all inpatient stays could be kept to a certain number of days or cost. Nothing else was necessary. This led to three outcomes that led to very subpar care. The first outcome was the deterioration of inpatient services. Rationing does not maximize state of the art care and practically all inpatient units are essentially observation services waiting for people to become less dangerous. Dialogue with patients on acute care units is essentially focused on that issue. Addressing the psychiatric disorder is a consideration only as it applies to dangerousness.  I have had many utilization reviewers tell me that they would no longer pay for the treatment of extremely ill people because they did not seem to be dangerous. 

The second outcome was splitting off addiction treatment. At some point, a large number of detox admissions were directed to psychiatry because medicine units no longer did detoxiification. Then at some point to capitalize on the DRG payments, psychiatric units not longer did detox. patients with addiction were sent from the ED to a county detox unit. The only time they came back is if they experienced seizures or delirium tremens.  The overall rationale is saving the insurance companies money.  They don't cover people at county detox units.

 The third outcome is that patients with severe psychiatric disorders are sent to jail rather than inpatient units. This has resulted in county jails becoming the largest psychiatric hospitals in the United States at a time when psychiatric beds per capita here are among the lowest in the world according to OECD data. All of these changes are associated with a tremendous lack of quality and would be a national embarrassment - if they were not viewed as cost effective by the businesses and governments in charge. The American Psychiatric Association and other district branches still incorporate the cost effective rhetoric when in fact, psychiatry left cost effective in the rear view mirror thirty years ago.

Psychiatrists don't have expensive procedures to order.  In psychiatry less is less (or no) time seeing a psychiatrist.  Less is no time being treated in a medically supervised and therapeutic inpatient or detox unit when you need it.  Less is no psychotherapy that might work for you.  Less is no case management services.  Less is no public health nursing.  Less is not taking the best medication because a pharmaceutical benefit manager says you will have to pay full price for it.  Less in no available child psychiatrist when they are needed.  Less is not getting your blood pressure checked in a public clinic because there are no blood pressure cuffs.

Less in psychiatry is obviously far less than any other speciality.

That brings me to the last concept in the article illusions of value. There is no greater illusion of value than current psychiatric care and that is not because of psychiatrists. To give a clear example, I am an excellent diagnostician - both medical and psychiatric illnesses. I can figure out what is wrong with people and come up with a plan to address all of those issues. I can't do it in a 15 minute appointment. I can't do it if I have to type up all of my encounters like a stenographer or waste my time supporting horrible electronic health record software. In the case of people with severe problems, I can't do it without staff people who can get the patient to the appointment to see me and make sure that the person follows up with all of my recommendations. Without all of that infrastructure on the outpatient side, I will end up seeing about 60% of the people who are scheduled and the average person coming back will tell me they are taking their prescribed medication half of the time. Almost all of that supporting infrastructure has been eliminated in the past 30 years and managed care organizations have set up psychiatric services based on the prescription of a medication. Even if you have a severe problem. Show up 3 or 4 times a year, have the psychiatrist ask you a few questions, and get enough refills until the next appointment.

Psychiatry is actually a paradigm that the rest of medicine should look to in terms of less is less. In her final sentence Rosenbaum describes "less is more" as an aphorism that is "better suited to telling coherent stories than to the complex decisions faced by doctors and patients." I could not agree more. My only qualifier would be that the administrators are always telling their coherent stories that make it seem like they know more than physicians know about medical practice. They do a great job of selling it and convincing people that a symptom checklist and an antidepressant prescription constitutes optimal care. 

That is the only way that the current abysmal psychiatric services offered by large health care corporations could get a pass.



George Dawson, MD, DFAPA







References:


1: Rosenbaum L. The Less-Is-More Crusade - Are We Overmedicalizing or Oversimplifying? N Engl J Med. 2017 Dec 14;377(24):2392-2397. doi: 10.1056/NEJMms1713248. PubMed PMID: 29236644.

2:  Sullivan K.  The rise and decline of the Dartmouth Atlas.  The Health Care Blog, September 25, 2016  http://thehealthcareblog.com/blog/2016/09/25/the-rise-and-decline-of-the-dartmouth-atlas/

Treatment Setting Mismatches - The Implications

Most physicians first experience with treatment setting mismatches occur when they are medical students and residents.  The ethos of medical training fosters an attitude of being put upon by the trainees - partly because they are or at least they were.  There was a history in American medicine as using the trainees in particular as inexpensive labor - doing all of the admissions to training hospitals and staffing them all night long.  In many if not most cases that meant long hours and minimal staff supervision.  The staff typically would hear about late night admissions only if they gave their resident team specific parameters to call them.

That work flow created tension in the system of care.  Depending on the institution teams could negotiate for admissions but typical the emergency department (ED) physicians had veto power in getting people in the hospital.  They were in the highest risk situation because they were responsible for what happened with discharges from the ED and they were responsible for getting patients out of the ED in a timely manner.  This led medical and surgical teams to view some of the admissions pejoratively as weak or dumps.  Many of these admissions were discharged as soon as possible - partly due to circumstances and partly self-fulfilling prophecy.  The treatment setting mismatches in these case could occur in both the ED and the hospital if the patient did not need to be there.  These problems has bee addressed over the part 15 years with the advent of hospitalists.  Hospitalists have a more enduring relationship with their colleagues in the ED.  There is more consensus on admissions and hospitals are staffed 24/7 by hospitalists rather than trainees.  That does not mean that the treatment setting mismatch has been solved.  You start to notice the issues involved with treatment setting mismatches after you are practicing medicine and you are no longer a trainee.  A few examples will illustrate this point.    


Hospital to Home

A 75 year old woman with diabetes mellitus Type 2, hypertension, and new onset atrial fibrillation is discharged home after two days in the hospital. She came in taking 5 medications but is leaving with 8.  She lives alone and during the nursing review at the time of discharge she knows how to set up the medications out of the bottles every day and the basics of what she needs to avoid in her diet.  There are some red flags with her medications in terms of potential interactions and symptoms that she needs to quickly report to her physician.  She currently has no primary care physician.  Her physician quit the practice and moved to a different clinic.  She tried making appointments with the other physicians in the clinic and had the feeling that "none of them like old people".  She is discharged with a bundle of medication side effect sheets highlighted by the nursing staff.  She is advised to review the highlights and report those symptoms to the clinic. 

Hospital to Facility

An 82 year old man with dementia and agitation is admitted to an acute care psychiatric unit.  He comes in with the message that his current facility will not take him back because he is too aggressive.  The initial assessment shows that he is barely mobile due to osteoarthritis but that he requires intensive nursing care for diabetes mellitus Type 2, wound care for foot ulcers, nebulizer treatments for asthma/COPD, and careful attention to his input and output each day because of moderate renal failure and a tendency to take inadequate amounts of fluids.  After two weeks of working with medical consultants, the attending psychiatrist realizes that there is no Skilled Nursing Facilities where the patient will get the level of care he is currently getting.  Without that level of care the patient will be dead in a few months. 

ED to Home

Patient X is a 50 year old man with alcoholism, alcoholic liver disease, and mild emphysema.  For the past three months he has been drinking 750 ml of vodka per day.  After an intervention with his friends and family he was referred to a substance use treatment facility.  The family was told at that time that he should be admitted to a detox facility because detox was not available at the treatment facility.  The patient decided to go to the ED.  He was given IV fluids and discharged 3 hours later with a prescription for lorazepam and told to go home and detoxify himself of go directly to the treatment setting.  He took all of the lorazepam on the first day and resumed drinking vodka.  He tried to get in to the original treatment facility and was turned down again because he still needed detox.

ED to Treatment Facility

The patient is at a local drug and alcohol treatment facility when he experiences a sudden acute mental status change.  He is confused and starts to experience auditory hallucinations part way through a detoxification protocol.  He asks to leave the treatment facility.  The facility and the patient's family convince him to go to the ED.  While there the staff treat him with benzodiazepines and IV fluids and tell him to return to treatment.  He tries that but the treatment facility disagrees with the ED and see his mental status and being too compromised to participate in treat.  He goes home and resumes drinking instead.

Hospital/ED to Jail

Patient Y a 29 year old man is detained by the police in a local shopping mall for creating a public disturbance.  He was panhandling. When none of the shoppers responded favorably he got very close to them and made loud threatening noises until the police were called.  When the police asked him to leave the mall, he shouted at them and threatened to kill them.  He was arrested but because the police suspected a mental illness he was taken to the emergency department for evaluation.  The arresting officers were hoping he would be admitted for further observation and treatment.  After the ED evaluation was completed as social worker came out and asked about what would happened if the patient was discharged to the street.  The officers responded that he would be arrested and taken to the local county jail.  At that point the patient was released on the basis that he was not dangerous and transported to county jail.   

These scenarios are all hypotheticals based on my experience.  Any physician with similar experience can cite hundreds of these examples and many, many catastrophic endings.  The common biases are that alcohol is not that much of a problem and that most people with chronic mental health and medical problems can continue to plug along with minimal assistance.  The error is to ignore the real dangers and not be focused on quality care that by definition solves and addresses clear health problems.

These scenarios all have some common dimensions.  First, the receiving setting is easily exceeded by the patient's medical needs.  In some cases the receiving setting is not medical oriented at all and is ill equipped to address medical problems.  Obvious examples are people who are discharged to jail or care facilities that are funded on the basis that they provide little to no medical care.  The scenario where the man with chronic (or in some cases acute) mental illness being sent to jail rather than hospitalized for effective treatment is one of the reasons why county jails have become the largest psychiatric hospitals in the USA.  It is one thing to recognize that fact but it is another to think about how that is happening.  In most cases hospitals have little to no bed capacity for psychiatric patients.  If they do - they are inadequately funded to provide complex care with inadequate staffing, length of stay, and in some cases inadequate medical and psychiatric coverage. At some point the politicians and bureaucrats decided to align the incentives so that level of care would be best provided in jail. 

Second, the discharge to inadequate facilities are driven by rationing of acute care facilities as "expensive and possibly unnecessary facilities".   That determination is complicated by the fact that receiving facilities have also been depleted by the same rationing mechanisms.  The reality of American healthcare at this point is that it is almost all rationed by a middleman who are incentivized to make as much profit as possible by rationing.  A great example is detoxification from drugs and alcohol.  Despite the fact that this process is potentially life threatening, at the minimum is associated with a high degree of distress, has significant psychiatric morbidity including suicide risk, and needs to be properly done in order to facilitate sobriety very few people in the USA are admitted for appropriate detoxification.  Like people with severe mental illnesses they are mostly sent home or to a facility with minimal to no medical coverage and then sent home.  In cases where a person is incarcerated they often go through acute detoxification with no medical assistance.  In many cases they suddenly stop opioids, benzodiazepines, or opioid agonist treatment (methadone or buprenorphine) and go through severe withdrawal in jail. 

Third, leaving a medical facility where there is intensive nursing care is like falling off a cliff for a lot of people.  There is no transition or assurance that many people can manage their own care in their own homes.  There used to be more options.  Public health nursing comes to mind.  Twenty years ago the attending physician could write an order and a public health nurse would see the patient in their own home and make sure that the transition was occurring properly and if not stay in contact with the patient and provide ongoing assistance.  That service was eliminated along time ago in order to reduce costs.

Fourth, an entire system of shadow care has evolved to make it seem like care is being provided when it is not.  Typical examples include health club discounts or a life style coach that calls you up on the phone and encourages you to be more physically active or eat less.  The ultimate advertising these days is a plan where you get a very modest health insurance discount through your employer if you sign up for one of these options and demonstrate compliance.  It makes it seem like both your employer and your health plan care about your health.  In the larger scope of things, it is nothing compared to the lack of care that happens in the above scenarios.

The final point to be made here is the irony of spending more money on health care than any other country in the world and having a large portion of it go up in smoke.  The source of that smoke is the huge administrative costs and profits of rationing health care under the guise that it is more "cost effective" or "efficient".

There is nothing cost effective or efficient about rationing poor quality care to patients.  The best evidence is during care transitions and the resulting treatment setting mismatches.


George Dawson, MD, DFAPA

The Largest Psychiatric Hospitals in the USA

In about 2012, I read an article that described the largest psychiatric hospitals in the USA as

1.  LA County Jail
2.  Riker's Island
3.  Cook County Jail

In the past month there is good evidence that in Minnesota, one of the most liberal states in the country - the situation is no different.  A recent study estimated that 25-30% of the jail population had a mental illness and 11% were on maintenance antipsychotic medications.  The  Hennepin County Sheriff Rich Stanek is quoted:

“What we’re seeing is crisis levels of mental illness among our inmates. This is solid evidence that our jails continue to serve as the largest mental health facilities in the state.” (1)

That same article refers to a Legislative Auditor's report describing the problem as widespread throughout Minnesota.  There is an alarming statistic that since the year 2000 there have been 770 suicide attempts and 50 suicides in Minnesota jails.  The article does outline some helpful measures.  Inmates will be screened by psychologists and psychiatric nurses.  The screening by psychologists is focused on low level offenders who can possible be released earlier,  although the offenses of the mentally ill were not substantially different from the non-mentally ill population.   The mentally ill inmates had a higher recidivism rate and were 30% more  likely to have 10 or more bookings at the jail. In a separate opinion piece (2), Sheriff Stanek reports that jail personnel are all going through 32 hours of crisis intervention training (CIT) to learn about the specific problems that mental illness causes and how to interact with people experiencing those symptoms.  The Barbara Schneider Foundation - a non-profit organization dedicated to end the criminalization of the mentally ill through positive training and education -  provides the training.  In his opinion piece the following quote is instructive:

"The urgent need for this training is a direct consequence of federal action requiring states to close our state psychiatric hospitals with no immediately viable community alternative. Our county jails should never have become the largest mental health facilities in the country."

I have previously written many times about the abysmal system of care that is available for people with severe mental illnesses.  In my experience, the people rationed out of the system include many of those who end up homeless and in jail.  If you have severe problems with mental illness that affect your decision-making, your social behavior, and your ability to assess the impact of your decisions you are at much higher risk  of an adverse interaction with the police or incarceration.  If incarcerated you are less like to have the resources to make bail, obtain and cooperate with an attorney, or follow the conditions of release. 

 These impairments combined with severely rationed resources accounts for the explosion of mentally ill in jails and this is not an acute problem.  It has been progressively worse over the past 20 years.  Stanek also call on the Governor and the legislators to provide finding for adequate placements (and hopefully supervision) and funding for CIT.  So far legislators have passed a law that allows Sheriffs to transfer mentally ill offenders to the limited beds at Anoka Metro Regional Treatment Center (AMRTC).  That has resulted in an increasing backlog of admissions of committed patients and increasing violence at the hospital.  Nobody in any of this controversy has spoken to the needs of the antisocial or career criminal with severe mental illness.  The issue of addiction and how that creates mental illness, criminal offenses, and leads to recidivism and worsening mental illness is also not addressed. 

In these articles and most, the families are left out of the equation.  The families I have seen are typically parents who have been dealing with the severe mental illness of their children for years.  They are shocked to find out that their children have been incarcerated instead of being hospitalized.  They are shocked that their children are not receiving any care for their mental illness while incarcerated especially that their medications have been acutely discontinued.  I have talked with many of these patients who were on methadone or buprenorphine for opioid addiction who had these medications acutely discontinued and went into opioid withdrawal until that resolved.  Psychiatrists everywhere have heard the pleas of these parents and their request to assist them in getting their child out of jail.  There is generally noting that can be done.     

 An associated issue is how government systems are managed at all levels.  In recent times, the idea that government systems can be managed like for-profit businesses that much show a profit for shareholders is all the rage.  It was one of the reasons that scientific and humane treatment of mental illness could be rationed out of existence.  Suddenly there was no longer a concern that a patient with mental illness was disruptive and might end up in jail or homeless if that behavior continued.  Now they had to be "dangerous" or the hospital asked them to leave.  When there were still too many demands on rationed beds they had to be "imminently dangerous" or they were asked to leave.  Sheriff Stanek and sheriffs across the country are dealing with the fallout of this managerial practice.  If people can't be treated in a cost effective manner (defined as getting them out in a defined number of days that are paid for)  they are not admitted.  Many of these patients are brought to hospitals by the police and not admitted because the hospital knows they will be taken to jail.       

The other problem of course is that jails are not really hospitals.  In today's political climate - even saying that out loud can set a dangerous precedent.  Even though Sheriff Stanek is doing what he can and he has a mandate by the Minnesota legislature allowing him to hospitalize patients on a priority basis at a state hospital, minimal to non-existent standards of care in jails do not make them hospitals.  The clear evidence from the editorial is the sparse medical coverage (1 RN very 12 hours for over a hundred mentally ill inmates), lack of adequate medical training (provided in this case by a not-for-profit foundation), and a lack of discharge resources for continuity of care.    

There are no psychiatric hospitals that can function or legally operate with that level of care.


George Dawson, MD, DFAPA



References:

1.  Chris Serres.  Mental illness in Hennepin County jail far higher than previous estimates, new study finds.  Star Tribune September 22, 2016.

2.  Rich Stanek.  Commentary:  Addressing the mental health crisis in our jails.  Star Tribune October 14, 2016.

Attribution:

1.  The photo is Hennepin County Jail from Wikimedia Commons.  The source information is by Micah (Transferred from en.wikipedia by SreeBot) [Public domain], via Wikimedia Commons.  The page URL is: https://commons.wikimedia.org/wiki/File%3AHennepin_County_jail.JPG

Just When You Thought American Healthcare Could Not Get Any Worse.....

I was on a vacation/family reunion last weekend about 150 miles north of the Twin Cities and 120 miles west of the only large northern metro area.  We were in the heart of lake country and about an hour from the closest emergency department (ED).  About 20 people of all ages there  for a few days to get reacquainted after a number of years, enjoy some good traditional foods, and outdoor activities.  Things were going very well until the last day.  Everyone was exiting the lake home to go to a local pizza establishment.  One of the family members missed the last step and fell hard to the pavement, knocking the lens out of his eyeglasses and sustaining a contusion/abrasion over the left supraorbital ridge.   No loss of consciousness.  He did sustain an abrasion on the left hand with some residual wrist pain.  He has some chronic medical problems but is not on anticoagulants.  Another family member is a nurse and applied an ice bag and cleaned a small laceration in the area of the abrasion.  It did not appear to need sutures and it was steri-stripped.

The only other bit of information that is necessary about the injured man is that he is 80 years old.  As a geriatric psychiatrist I ran down the usual considerations of the old approaching the old old - especially anatomic traction on bridging veins and subdurals from that injury.  I did not want to miss any needed brain imaging protocol based on these factors.  I decided to call the local hospital emergency department and run it by the triage nurse.  The call went like this (this is not a transcript).

Hospital:  "Can I help you?"
Me: "Yes - I am currently out at a lake cabin and a family member took a fall and struck his frontal area.  No loss of consciousnesses, headache, visual change, or neurological findings.  I would like to talk to your ED triage person to see whether imaging is indicated."
Hospital:  "Is he from Minnesota?"
Me:  "No he is not."
Hospital:  "We cannot allow you to talk with the ED if he is not from Minnesota.
Me:  "Are you sure about that?"
Hospital:  "Yes very sure."
Me:  "I am a physician - is there any way that I can talk directly physician-to-physician with an ED physician."
Hospital:  "No you can't.  You have to call the number on the back of the insurance card."

That was a precedent setting call for me.  I did not identify myself as a psychiatrist, but I have really never encountered this kind of administrative obstacle to medical care.  I viewed my question as an important one and one that an ED physician would probably know more about than me.  In that context there was something about an out of state resident not getting equal access to medical care.  I am sure it would be easier to get access in France or Germany than it was in Minnesota.  I collected the medical card and made a second call to the nurse triage line listed on the back of the call.  My experience with nurse triage lines is that they at least call the physicians on call and get some semblance of an answer to your question - even on the weekends.

Me:  Explaining the situation again in its entirety and giving all of the relevant insurance information both on and off the card.  The off card data included date of birth and three repeats of a call back number.  It was at that point the triage nurse said:
Triage RN:  "Well I am afraid I can't help you because you have to talk with a nurse who is licensed in the state where your relative resides.  But I will transfer you."
Me:  "OK"
Cricket sounds and bad muzak for about 5 minutes.
Triage RN (back on the line):  "The wait times are too long.  Let me just tell you that as long as he has no headaches, nausea, vomiting, visual changes or neurological symptoms - you can just watch him.  Bring him to the ED if any of those symptoms occur."
Me:  "OK - there is no imaging study given his age?"
Triage RN: "No".

As multiple posts on this blog can attest - I am openly critical of how business and government interests have rationed access to health care.  I had really never imagined obstacles to standard health care based on your state of residence.  I had never encountered a system that refused physician contact with another physician in their system.  I can see the gears turning on how to turn these calls into billable fees, even if it means a steep out-of-pocket payment by the patient.  But even in that case giving me the correct medical information is money in their pocket if it results in a CT scan.  Medical imaging generally covers about one-quarter of the operating budgets of hospitals these days.

For now it appears that after hours physician consultation may be rare and a sequence of calls based on legitimate concern needs to be answerable by a triage nurse's database or a visit to the emergency department.

And you better hope that you are in the right state.



George Dawson, MD, DFAPA




Supplementary (posted on August 23):

Getting back home and doing a little more research shows that both the Emergency Medicine (2) and Internal Medicine (1) literature say that age alone is an indication for a CT scan following a minor TBI.  UpToDate says that age 65 years of age or older is an indication.  The emergency medicine literature uses New Orleans Criteria suggesting an age of > 60 and the Canadian CT Rule suggesting an age of > 65 under CT if any criteria present.  According to these criteria - age alone is an indication for a CT scan.

1:  Randolf W. Evans.  Concussion and mild traumatic brain injury. In: UpToDate, Aminoff MJ, Moreira ME (Eds), UpToDate, Waltham, MA (Accessed on August 22, 2016). - see graphic 50743.

2:  Haydel M. Management of mild traumatic brain injury in the emergency department. Emerg Med Pract. 2012 Sep;14(9):1-24. Epub 2012 Jul 20. Review. PubMed PMID: 23101569. (full text online).


Attribution:

That's me walking on a dock in Lake Country.

The Fifth Inconvenient Truth

Thomas Insel, MD the current head of NIMH captured a few sound bites in a recent edition of Psychiatric News.  In it the following Inconvenient Truths were mentioned:

1.  The field has failed to “bend the curve” in the prevalence and cost of mental illness;

2.  More people are getting more treatment, but outcomes are not getting better.

3.  The current knowledge base is insufficient to ensure prevention, recovery, or cure for too many people with serious mental illness.

4.  A transformation of diagnostics and therapeutics is necessary to make significant progress in treating mental illness.

Any head of a politically funded agency has to carefully parse his or her rhetoric in a manner consistent with his main goals.  I would see his main goal as getting funding for NIMH and in that role he needs to speak to the politicians who hold the purse strings.  That is really the only reason why cost is included in his first sentence.  The cost estimates both within the United States and world wide have been calculated many times and they are staggering.  There are well known estimates of disability that show the disability due to mental illness and addictions are routinely in the top ten causes.  But what  about the cost of treatment?  The cost of treatment has been flat to decreased for about three decades now largely as a result of managed care rationing with a disproportionate hit being absorbed by psychiatric services.  I have argued repeatedly that cost needs to be taken off the table in these discussions at least until the mental health infrastructure gets on even par with cardiology or oncology.  The whole idea that you can produce equivalent results with practically no resources strikes me as absurd.  The only thing more absurd is that we are supposed to be even more cost effective.  Compared with the rest of medicine we are looking at cost effective in the rear view mirror.  We crossed into the "on the cheap" zone a long time ago.  As expected, cost effective is synonymous with low quality.  Since we have abandoned quality reviews with managed care we have abandoned that word.  A more appropriate observation would have been:

The field has failed to “bend the curve” in the prevalence and quality of care of mental illness.

The second issue is a brief lapse into rhetoric of vagueness.  Who is "the field" here?  Are we referring to psychiatry, other mental health professionals, primary care physicians who do 80% of the psychopharmacology,  or the managed care systems and systems with the same techniques that rigorously ration mental health care?   The meaning of the sentence changes dramatically by substituting each of those words.

To the second point on more treatment not leading to better outcomes it is fairly easy to show why this is the logical outcome of rationing.  I have posted many times about how inpatient psychiatry has become sham treatment based on dangerousness criteria and corporate priorities.  You don't need any research to show that if you are cycling people with serious mental illnesses in and out of short stay psychiatric units in 3 - 5 days and basing their stay there on whether or not they are "dangerous" and using treatments that take weeks to work that by definition you are appearing to treat many more patients but providing adequate treatment to very few.  You don't need any research to show that when you shift mental health care from psychiatric units run by psychiatrists to county jails that the outcomes will be worse.  You don't need any research to show that when people do not get research based psychotherapies in the manner that they were designed and instead get a few crisis oriented sessions that do not address their basic problems that outcomes cannot hope to be better.  When your attitude is that all mental health treatment can proceed by treating common problems with definite social etiologies with medications as fast as possible and not having an intelligent conversation or working alliance with the person affected - it is logical that treatment outcomes will not improve.  Treatment outcomes do not improve if you do not provide effective treatment and that is the mental health landscape at this time.

Dr. Insel's third point should read:

The current knowledge base is not used to ensure prevention, recovery, or cure for too many people with serious mental illness.

I am not by any means suggesting that it cannot be improved upon.  There is no place in medicine where that is not the case.  When services are globally rationed and we are still beating the drum about "cost-effectiveness" we cannot expect inmates to have access to DBT or GPM to treat their borderline personality disorder.  We cannot expect them to get exposure therapy to treat PTSD from psychological trauma.  We can also not expect managed care patients to get this from 2 or 3 sessions of crisis counseling when they need a more specific research based psychotherapy.

The fourth statement is the only one that I have no issue with.  It is a statement that is generally true for most chronic illnesses.  I have many posts here about asthma for example.  Asthma is an illness that many primary care physicians believe that they really have made inroads in treating.  It is a great comparison for mental illness and even chronic mental illness because the fact is that most asthmatics are chronically symptomatic despite treatment.  The reason is a combination of a biologically complex disease, partially understood disease mechanisms, and a medical treatment model that involves seeing the patient every 3-6 months and prescribing them medications that are often partially effective at best.  There is really minimal medical intervention beyond that except for acute hospitalizations.  That is the exact level of care that we provide for mental illness in this country.

A lot of people fault Dr. Insel for being an advocate of neuroscience.  I may be one of the few who does not.  As a student of the brain and brain plasticity things are incredibly complex.  As politics get projected onto that complex system - science is often left in the lurch.  People see the results of a complex situation simplified as a meta-analysis and see the results as supporting both ends of a political argument.  I would go back to the asthma example.  The signaling in that disease is much less complex than signaling in the brain and there are far fewer cell types involved.  Asthma endophenotypes followed the elaboration of endophenotypes in schizophrenia and so far nether has resulted in clinical innovation.  I would argue that the treatment outcomes in most mental illnesses are on par or better than the treatment of asthma.  And yet there is no national research administrator of Dr. Insel's stature talking about the lack of progress.  I think the reason is clear - there are not nearly as many political arguments projected onto asthmatics.

If I fault Dr. Insel for anything it is for not knowing what has happened to the mental health system of care in the USA.  It is not due to a lack of technology, but an obstruction of current technology transfer.  He is not alone in routinely ignoring this as the central problem with psychiatric services today.  Any number of people do and in the process usually promote their own theories of why we are mired in the current environement.

That Fifth Inconvenient Truth?  Must be obvious by now but in the event that it is not:

Ration mental health and addiction treatment, ignore current research proven treatments, and reduce treatment to the prescription of medications and poor outcomes will follow.

You can take that to the bank.


George Dawson, MD, DFAPA