How Can Psychiatry Save Itself? Part 2.

Ronald Pies, MD just published his second article in a two-part series on "How American Psychiatry Can Save Itself". This essay contains specific recommendations for change. I was surprised to see that it was written from the perspective of "the American public is disenchanted with psychiatry and how the profession needs to address these issues". He attributes the public relations problem to a number of factors including the lack of "robustly effective, well-tolerated treatments", ties to the pharmaceutical industry, the declining use of psychotherapy, the public's lack of understanding of current effective treatments, and essentially political attacks by anti-psychiatry groups and other sources.

It is disappointing to see the formulation of the problem as basically one of public relations. Dr. Pies observes that the public really doesn't care about what was or what is in the DSM or the model that is used for mental illness. It is historically obvious that the only reason that psychiatry has been tolerated over the years has been our availability to treat people with obvious problems. It is difficult to deny that mental illness exists when you have brought your catatonic family member into the emergency department because they have not been able to eat or drink for two days. That fact alone is the reason that decades of anti-psychiatry abuse has been a nuisance but has not destroyed the profession. The main problems these days is that it has morphed into a brisk business for many of our detractors and whatever legitimate media is out there does not seem to be able to separate the wheat from the chaff.  In the case of psychiatry there is an incredible amount of chaff.

Dr. Pies has six fairly specific recommendations based on this public relations problem. I have listed them in table below along with my responses. This places him at a distinct advantage because I am in the position of reacting to his statements. I will offer my solutions further along in the article and hope for his rebuttal or the rebuttal of anyone else reading this article.

Dr. Pies	Dr. Dawson
1. Change the name of the DSM to the Manual of Neurobehavioral Disease or MND. Another option would be Manual of Psychiatric Disorders.	I generally avoid the term "behavioral" because it is a political term used by managed care companies to disenfranchise psychiatry or behavioral neurologists to suggest that they know more about human behavior than psychiatrists do.  Every time we use the word "behavioral" rather than psychiatry we lose to somebody.  Neuropsychiatry anyone?
2. Emphasize the importance of suffering and incapacity as hallmarks of disease and eliminate any condition that lacks those features.	I don't think the DSM is that confused in the "Cautionary Statement" or "Definition of Mental Disorder" (xxi) when it describes mental disorders as "a clinically significant behavioral or psychological syndrome or pattern that occurs in individual and that is associated with present distress or disability or with a significantly increased risk of suffering death, pain, disability, or loss of freedom.” There are additional details.
3. Separating clinical descriptions of disease from research oriented criteria using prototypes for the clinical descriptions.	This might be a useful public relations move but experienced clinicians already do this and there is some movement in DSM5 to already capture this, namely the elimination of schizophrenia subtypes.
4. Understand diagnostic categories as tools in the service of medical-ethical goals.	I think that experienced clinicians also currently do this.
5. Biological data is regarded as supporting but not finding disease categories and the diagnoses would remain clinical.	That is probably a state-of-the-art, but biomarkers may be fast approaching that can define more homogeneous categories of disease and more specific and successful treatments can be offered.
6. Parsimony with regard to the number of diagnostic categories.	Agreed and at some point we should be able to use mechanisms of disease to parse the categories. A hopeful but at this point speculative example would be the role of the ventral tegmental area in both addictions and amotivational syndromes.

From the opinions I have offered it should be apparent that I think this plan is a fairly weak one. In order to come up with a strong plan, the major problem affecting psychiatrists and the delivery of psychiatric services needs to be in clear focus. When I look at Dr. Pies suggested solutions he has public relations and the diagnostic manual in his focus. I suppose you could argue that public relations is always important and that the diagnostic manual is essentially a public relations nightmare particularly when you're considering the arguments of people who are not trained clinicians and who have their own agendas and are looking for easy press.  I don't think the American Psychiatric Association has the resources to engage the thousands of anti-psychiatry and special interest groups who want to make headlines by critiquing the DSM5.

In order to save American Psychiatry the problem needs to be clearly recognized. The single most destructive force to American Psychiatry without a doubt is managed-care and that includes managed care companies that are for-profit, managed care companies that are not-for-profit, pharmaceutical benefit managers, and government agencies that are using managed care strategies to ration psychiatric care.   Within the space of two decades they have essentially shut down half of the inpatient bed capacity, they have turned inpatient units into high-volume and very low quality discharge mills, they have created a similar assembly line in outpatient clinics, they have added hours of free work from physicians frequently to justify their financial decisions, and they claim to be one of the great purveyors of quality treatment in medicine in the United States. How can that travesty possibly be ignored? All of the other threats to American Psychiatry pale in comparison.  We have become a profession that is essentially defined by the managed care industry.

To reverse that trend and actually save psychiatry the following steps need to be taken:

1. Managed care, pharmaceutical benefit managers, and managed-care tactics being applied by the government and government proxies need to be clearly identified as the problem. There needs to be a concerted effort to reverse the political and tactical gains made by this industry and most importantly reclaiming the quality ground. The managed care industry is currently represented by NCQA, and its role as an accreditation entity. Anyone who has looked at their standards for mental health care should be appalled. Every professional organization that has psychiatrists as members should be critiquing this organization and posting their own quality standards.

2. Professional psychiatric organizations need to maintain the edge in terms of quality and standard of care guidelines. We cannot afford to have guidelines that are 5 to 10 years out of date they need to be up-to-date and current. If the American Psychiatric Association is not up to the task, other professional societies should post current guidelines in their areas of expertise. You cannot possibly win political battles against an industry special interest group by using dated and incomplete guidelines and standards of care. An excellent example of psychopharmacology guidelines is available on the British Association of Psychopharmacology website.

3. The education of future psychiatrists is critical and that makes the issue of managed care and assembly-line psychiatry an even more immediate problem. We cannot possibly expect psychiatrists to train for an additional one or two years if they are going to be paid $22 or less to see a patient. There are not enough "medication management" visits in the world to fund for that additional training and a professional salary. Unless concrete changes occur in the practice landscape the future of current psychiatric training is at risk and there is no point in speculating on how it can be enhanced.

4. In the event that adequate funding is available for training and the future profession I would recommend changes in the total time of residency and psychotherapy training but in a different manner than that suggested by Pies.  I would opt for adding a two-year neuroscience rotation and pool resources with departments of neurology and neurosurgery for a joint rotation to focus on the latest neuroscience applications to psychiatry, neurology, and neurosurgery. In the near future genomics and neuroscience will be required training and the associated philosophy can be taught at the same time during discussions of modeling at various levels.

In terms of psychotherapy, the first thing that we can do is recognize the progress that has been made in residency programs as well documented in the Archives article by Weissman, at al.  It was not that long ago that a number of "biological psychiatrists" were walking around and annoying the rest of us by proclaiming that "I don't do talk therapy".  A psychiatrist trained in psychotherapy applies that continuously in their work and uses it to inform the structure of treatment. Some of the best psychiatrists that I have encountered do psychotherapy in as little as 10 or 20 minutes and the patients they saw during that time found those discussions to be very beneficial.

Psychotherapy today can also be informed by the New England Journal of Medicine article written by Kandel over 30 years ago when he described how neuronal plasticity is affected by human encounters. The teaching of psychotherapy today can be used both as a technical tool to teach patients and a heuristic tool to teach staff and residents about human consciousness and its biological basis. Newer forms of psychotherapy such as Acceptance Commitment Therapy and Mentalizing therapy provide theories and an explicit roadmap and how to provide research proven and effective psychotherapy that takes human consciousness into account.

5. Political attacks by prominent government officials cannot be tolerated. It is no longer acceptable to suggest that all psychiatrists are corrupted because some psychiatrists are being paid to give presentations for drug companies or to do research. The suggestion that the DSM5 is corrupted, by ties to the pharmaceutical industry can be dealt with. There are clear strategies to deal with some of the blanket claims by Congressional critics.  I can never understand how an entire profession became criticized because of the fact that some members were legitimately being paid to work by the pharmaceutical industry. I cannot understand how a member of Congress can decide to investigate private employment arrangements between an employee and employer or say nothing when no problems are found. I cannot understand how member of Congress with significant conflicts of interest is allowed to treat our profession with impunity when his conflicts of interest are never discussed.

6. Board certification has become a business that is rapidly aligning itself with the business of running medical boards and managed-care corporations. The goal of ongoing professional education should be to bring all practitioners up to the same standards and there is no reason that board examinations are necessary. There is no evidence that they can achieve that goal. This was clearly an arbitrary political decision by the American Board of Medical Specialties and it should not be tolerated by practitioners in the field. There is precedent for forming independent boards and I would refer to the American Society of Addiction Medicine as a clear example. If the ABMS, is no longer relevant - a better solution would be to form a new board that meets the needs of clinicians instead of purported political goals.

7. Quality based standardization of local practice is an attainable goal. One of the practical problems in any medical specialty is the fact that there are outliers. There is a robust solution to this and the best example I can think of is the Wisconsin Alzheimer's Institute Dementia Diagnostic Clinic Network.  The network is a statewide collaboration of independent clinics that receive guidance and updates from a central university-based clinic specializing in the diagnosis and treatment of dementias. Patients anywhere in the state of Wisconsin or their physicians can refer to a local clinic to receive state-of-the-art diagnostics and treatment recommendations. This model solves two problems for psychiatry. The first is access to state-of-the-art psychiatric treatment and the second is practice drift by practitioners especially the outliers. It also solves a third problem of ongoing education.  There is no reason why collaborative networks like this one could not be established for mood disorders, addiction, schizophrenia, anxiety disorders, and personality disorders. Training at all levels could be guided by the principle that psychiatric residents need to have the necessary skills to get into these networks and implement the guidance suggested by the central academic center.

That is the path I would take to save American psychiatry. It is not an easy path but it is a realistic one. Any psychiatrist who has been practicing for the past 10 or 20 years realizes that the practice environment has deteriorated rapidly and despite all of the talk about a shortage of psychiatrists, the current lot of psychiatrists is being worked to death and they are trapped in a paradigm that results in high volume and low quality work.  The main problem is that there is no foreseeable professional organization that can carry it out. The APA does not have the political will, expertise, or leadership to do it and in that regard the future does not look good. I think that also implies that the APA has really underestimated how far psychiatry has fallen and how much they have played a role in that fall.  I see an occasional glimmer of hope, but as long as we have an ineffective structure and an election process that rewards academic achievement rather than a vision for psychiatry in the 21st century, progress will remain difficult if not impossible. We have already been replaced by a generation of "prescribers" in some areas and managed-care and the government would not complain if that occurred everywhere.

George Dawson, MD

Ronald Pies, MD.  How American Psychiatry Can Save Itself: Part 2.  Psychiatric Times March 2012, vol XXIX, No 3: 1, 6-8.

Myrna M. Weissman; Helen Verdeli; Marc J. Gameroff; Sarah E. Bledsoe; Kathryn Betts; Laura Mufson; Heidi Fitterling; Priya Wickramaratne. National Survey of Psychotherapy Training in Psychiatry, Psychology, and Social Work.  Arch Gen Psychiatry. 2006;63(8):925-934.

Kandel ER. Psychotherapy and the single synapse. The impact of psychiatric thought on neurobiologic research. N Engl J Med. 1979 Nov 8;301(19):1028-37.

Another Lesson from the Business World

When you are in business  the goal is to make money.  The interpersonal aspects of that continuum range from "The business of business is business" to "The customer is always right."  An op-ed piece in the New York Times introduces us to another approach to making money and that is with the client or at the expense of the client.  A Wall Street insider gives us a rare glimpse into one of the largest investment banking firms and how their culture shifted over the past two decades to focus on profiting from their clients rather than profiting with them.  That same firm was already accused in 2010 of selling its clients mortgage-backed securities and betting against them.  A professor of corporate governance from the University of Delaware commented about how the structure of these companies changed as they became public and started to look for as many clients as possible.

For the same period of time the change in corporate governance of healthcare corporations has also gone through a revolution. There has been a shift from medical guidance to business guidance. Many if not most clinics and hospitals have changed their corporate governance so that doctors are subordinate to businessmen.  The changes are often very subtle but the overall process has a focus on making money rather than optimal patient care. There is plenty of window dressing along the way that is frequently sold as quality but the bottom line is that any physician or patient will generally sustain some kind of significant cost dealing with a healthcare corporation or pharmacy benefit manager.

When physicians are taken out of the loop, the business  of medicine is no longer treating illness and alleviating suffering but it becomes making money and the only way that happens is to profit from patients and get as much free work as possible from doctors.

George Dawson, MD

Nelson D. Schwartz .  A Public Exit From Goldman Sachs Hits at a Wounded Wall Street.  New York Times March 14, 2012.

Greg Smith. Why I Am Leaving Goldman Sachs.  New York Times March 14, 2012.

NYTimes Tells You How to Rate Your Doctor

The New York Times has a feature (see first reference) that discusses why the number of Internet reviews of physicians is sparse and the quality is poor.  The main contention is that people are too intimidated to rank physicians. The author ignores the profit motive of all the sites as a potential conflict of interest and leaps to the conclusion that the AMA speaks for most physicians even though only about 29% of physicians are members of the AMA.  He also describes physicians as "untouchable" when in fact at least 20% of physicians can be expected to be sued for malpractice during their lifetime and malpractice lawsuits have resulted in entire specialties migrating from a particular state. That is hardly what I would describe as "untouchable".  He is openly critical of the president of the AMA suggesting that anonymous, undocumented, and unverified reviews are probably not the best source for a physician recommendation.  He quickly invalidates "disproportionately positive reviews" on some websites is the product of an "unquestioning mindset".

The worst part of the article is leaping ahead to the Medicare initiative and their physician report card. Nevermind the fact that the risk adjustment concern by the AMA is legitimate.  Nevermind the fact that there is really no valid way to compare physicians at this point in time.  Nevermind the fact that there are political interests at play in particular the managed-care industry and how they can potentially game the system in favor of their principles. The author basically is encouraging people to go full speed ahead.

The result of that experiment is fairly predictable. The only thing I am hoping is that Google will come up with a way to prioritize the relevant information about physicians such as where they really practice and how to get a hold of them instead of the pages and pages that you currently encounter when you are trying to find a physician.

The AMA doesn't give much better advice in their recent edition of the amednews.  In a piece entitled "Physician rating website reveals formula for good reviews", their first suggestion was to not have a patient waiiting for more than 15 minutes and no more than 10 minutes in the exam room.  I can't think of any practice where the physician has that kind of control over their schedule - even if they postpone all of the documentation and stay for several hours after the clinic closes to get it done.  The business experts observed:  "overall ratings were based on time in the waiting room and the exam room -- rather than perceived clinical quality".  Keep that in mind when you are looking at online ratings of physicians.

I would suggest an experiment of my own that I have conducted several times with a high degree of success.  Imagine that you have a serious medical condition that requires a high risk procedure and you want to find the best physician to help you.  Your search process will involve the Internet, but it does not involve looking at any of the ratings you find when you search on a physician's name.  What do you do?

I will come back and answer that at a later date and discuss how that needs to be modified when you are looking for a psychiatrist.

George Dawson, MD

Ron Lieber.  The Web Is Awash in Reviews, but Not for Doctors area Here's Why. New York Times March 9, 2012

Pamela Louis Dolan.  Physician rating website reveals formula for good reviews.  amednews. Feb. 27, 2012

Mismanagement of Knowledge Workers

In a previous post,  I discussed Drucker's concept of “knowledge workers” and how that concept applied to psychiatrists and physicians. The basic concept is that knowledge workers know more than their managers about the service they provide, work quality is more characteristic than quantity, and they are generally considered to be an asset of corporations.  I pointed out that physician knowledge workers are currently being managed like production workers and referred to common mistakes made in managing physicians and psychiatrists. Today I will tell attempt to describe how some of that mismanagement occurs using examples that psychiatrists have discussed with me over the past several years.

Inpatient psychiatry has taken a severe hit over the past 20 years in terms of the quality of care. Many people have talked with me about the discharge of symptomatic patients occurring in the context of high volume and low quality. Depending on the organization, a psychiatrist may be expected to run an outpatient clinic in addition to a busy inpatient service or in some cases provide all the medical services to the inpatients with minimal outside consultation. Most hospital care is reimbursed poorly despite political suggestions to the contrary. Psychiatric DRGs are typically 20% less than medical surgical DRGs and they are not adjusted for complex care. Administrators generally "manage" psychiatrists in a way to make sure that inpatient beds are covered. That frequently means that psychiatrists who prefer practicing in an outpatient setting end up doing some inpatient care. An outpatient clinic may be canceled so that a psychiatrist is available to run an inpatient unit. There have been situations where inpatient beds or whole units have been shut down for lack of psychiatric coverage. The only explanation given is that there is a "shortage" of psychiatrists.

I had the pleasure of running into one of my residency mentors in an airport last May. I let him know that I was just finishing up 21 years of inpatient work and moving on to something else. He smiled and said: "Three months wasn't enough?".  I always liked his sense of humor but there is also a lot of reality in his remarks.

I don't mean to imply that it is any easier on the outpatient side. If you are a manager, what could be easier than having a unit of production that you could hold your employees to? It turns out there is something easier and that is being able to set the value of that unit of production. That is what RVU based productivity is all about. A standard managerial strategy these days is to have a meeting with an outpatient psychiatrist and show them how much they are "costing the clinic" based on their RVU production. Spending hours a day answering phone calls, doing prior authorizations, questions from other clinicians, curbside consultations, discussions with family members, and documenting everything doesn't count. I have had the experience calling a clinic at 7 PM and hearing keyboards clicking in the background. I have asked outpatient colleagues how they are able to produce outpatient documentation themselves and still get out of clinic on time. Now that I work in an outpatient setting myself, I know what they were telling me was accurate and that is the documentation gets deferred until later.

The mismanagement does not stop there. At some point in time medical schools decided that there were also going to start basing faculty salaries on clinical production. I suppose every medical school as a formula for converting teaching and research time into production units, but until I see those formulas my speculation is that any activity that does not result in billing leads to lower compensation. The days when physicians were hired as teachers and academicians seem to be gone.  Because of discriminatory reimbursement, departments of psychiatry will be disproportionately affected.

Within psychiatry there used to be an interest in organizational dynamics and how they impacted patient care. The dynamics in most organizations today are set up to promote the business. That has produced a focus on high volume-low quality or in some cases supporting the specialty with the highest reimbursement and procedure rates.   Associated dynamics are in place to select and shape an idealized corporate employee who will modify his or her practice according to the whims of the Corporation. It may be hard to believe but large medical corporations everywhere are trying to figure out how to recruit young physicians who believe in their models. Physicians who don't accept these ideas frequently find that the company is not very friendly to them. There are always various political mechanisms for ousting any dissidents and there is minimal tolerance for debate.  The dissent can be as mild as asking why consultants with less expertise than the physicians in the practice are being called in to critique them and come up with a plan.

When it comes to physician mismanagement there are few businesses that can equal the government. RVUs, the Medicare Physician Payment Schedule, pay for performance, and various failed political theories like fraud as the cause for healthcare inflation, and managed care amplifying all of the above and focusing all of that irrational management directly on physicians.  The result is obvious as enormous inefficiencies, job dissatisfaction, and demoralization. Governments partnering with businesses and placing business practices like utilization review and prior authorization in state statutes increases the burden exponentially. At the heart of this conflict is a physicians training to be a scientific critical thinker and function autonomously with the businesses interest of making a buck. Despite all the lip service to quality, business decisions are always made on a cost rather than quality basis.

It is often difficult to see any light through the blizzard of government and business propaganda that passes for the management of physicians and psychiatrists. Psychiatry has bore the brunt of mismanagement over the past 20 years and that has well been well documented in the Hay group study showing the disproportionate impact of managed care on our field. Inpatient bed capacity has dwindled and the beds that have not been shut down are managed for high-volume low quality work. Outpatient clinics including those run by and nonprofits are managed according to the same model.  Businesses and governments have provided the incentives for this type of practice.  The available consultants in the field only know an RVU based productivity model and nothing else. Rather than treating psychiatrists as knowledge worker assets, the available jobs frequently reduce us to micromanaged clerical workers utilizing about 10% of our knowledge.  It should be no surprise that the environment makes it seem like anyone can do the job.

One of my favorite quotes from Peter Drucker was: "More and more people in the workforce and mostly knowledge workers will have to manage themselves".   After all, only  the knowledge worker knows how to best complete the job.  Every psychiatrist that I know, knows how to get the job done and it is often at odds with what we are allowed to do. The best pathway to do this is to optimize the internal states of the knowledge workers and create environment where they manage themselves.  There are very few environments available where that can happen today for psychiatrists.

George Dawson, MD

Physician oversight or intimidation?

The Board of Medical Practice in the state of Minnesota regulates 20,000 physicians. Most of them are employees in large healthcare companies. That means they have to undergo the credentialing process within those organizations as well as collateral organizations in addition to renewing their state license every year. There are about 800 complaints against physicians with the board of medical practice every year and the board takes serious actions based on those complaints at the rate of about 1.29 serious actions per 1000 physicians.

In Minnesota, anyone can complete a formal complaint against any physician. A specialist at the board sends a letter with the complaint to that physician's office and they have two weeks to respond to the complaint. That generally involves a specific letter to address the complaint as well as all of the associated medical records.  Frequently several physicians or clinics are part of the complaint in the process cannot go forward until all of the responses have been received by the Board.  The physician must respond literally to the complaint as written by the complainant.   The complaint is never interpreted by the Board.  The Board renders a decision based on the information it receives.

Like many states there is a move by politicians and the news media to suggest that doctors are not regulated tightly enough and they are not punished thoroughly enough in the state of Minnesota. The local press has been beating that drum for the past month.

There is now a clear case to be made that some of these complaints have little to do with medical practice and more to do with politics.  Many of us have seen it happen to our colleagues. I am familiar with several cases where a physician was accused of having a problem with other staff. The descriptions of those problems varied from being "disrespectful" to "snubbing" another staff member. Even in the case of unsubstantiated complaints there are protocols available in the Twin Cities that allow for physicians to be fired, written up, or rehabilitated based on purely subjective complaints. That is a far cry from the concerns about "disruptive physicians". It is apparent that in many settings purely subjective and essentially political complaints are being made on physicians and advanced by their administrative hierarchies.

Before anyone plays the "you're just defending physicians" card consider this. There is no physician I am aware of who would not agree with disciplining a physician who is physically abusive, verbally abusive, or otherwise out of control. There is no physician I am aware of who wants to see an incompetent physician practicing anywhere regardless of the source of their incompetency.  The people who escape criticism in the issue of physician discipline are not physicians but anyone who stands to gain from the proposition that there continue to be physicians who endanger public safety and there are widespread undetected numbers of them out there practicing.

Clearly the media has a stake in this process. The letter by Dr. Langland points out that the media in this case certainly could have done a better job investigating the major points of their contention that the medical board is failing in its public safety mandate. At a national level, Public Citizen obviously has a lot to gain by its ranking of medical boards and suggesting that ranking has a lot more meaning than it really does. Politicians at all levels get a lot of mileage out of keeping professionals accountable. That is true whether they are teachers or physicians. The irony is that politicians at all levels are clearly some of the least accountable people out there. I have also posted clear evidence that their approach to holding teachers "accountable" with an emphasis on standardized test score results is exactly the wrong approach to improving student test scores.

There are clearly a lot of people with a lot to gain in pushing this agenda and that conflict of interest is never discussed. The objective evidence is also never discussed. But I want to draw attention to a key paragraph in Dr. Langland's letter and that is the paragraph below:

"The Star Tribune also expresses concern that a majority of 74 doctors whose privileges were suspended or revoked by hospitals or clinics did not receive disciplinary action. Again, I am very familiar with these situations, most of which do not involve substandard patient care. Often they result from personality conflicts, turf battles and competitive issues. The board has correctly not let itself be drawn into these battles." (see reference 1)

This is a rather stunning revelation. It suggests that some organizations that are punishing physicians for what are essentially subjective or political complaints are also filing those complaints with the Board of Medical Practice and looking for them to be legitimized. While it is good to know that the current board has been able to see those complaints for what they are, there is no guarantee that will always be true. With the increasing influence of businesses and their agenda to control doctors, at some point in the future we may see these trivial complaints suddenly become complaints that threaten a physician's license and livelihood.

That is a heavy price to pay for the cost of doing business.

George Dawson, MD

1.  James Langland.  State Medical Board is Sound.  StarTribune March 5, 2012

2.  Star Tribune Editorial Board.  Medical Board Fails Quality Examination.  StarTribune February 25, 2012

3.  Medical Board actions against doctors, per 1,000 doctors, 2010.  StarTribune  February 6, 2012.

4.  Glenn Howatt and Richard Merryhew. State panel: Public deserves more information about physician misconduct.  StarTribune February 27, 2012.

5.  Glenn Howatt and Richard Merryhew. Doctors who err escape penalties.  StarTribune February 5, 2012.

Violence and Gunplay - Why Nobody is Informed by the Media Anymore

Mass shootings have been a phenomenon of my lifetime.  I can still clearly remember the University at Texas-Austin shootings that occurred  on August 6, 1966. A single gunman killed 16 people and wounded 32 while holed up on the observation deck of an administrative building until he was shot and killed by the police. I first read about it in Life magazine. All the pictures in those days were black and white. Some of those pictures are available online on sites such as "Top 10 School Massacres.”  I generated this timeline of mass shootings when Google still had that feature in their search engine. 

The problem of course is that the mass shootings never really  stop.  In the USA, the press is so used to them that they seem to have a protocol.  Discuss the tragedy and whether or not the perpetrator was mentally ill, had undiagnosed problems or perhaps risk factors for aggression and violence.  Discuss any heroic deeds. Make the unbelievable statement that the victims were "in the wrong place at the wrong time."  And then move on as soon as possible.  There is never a solution or even a call for finding one.  It is like everyone has resigned themselves to to repetitive cycles of gunfire and death.  It is clear that the press does not want to see it any other way.

When you are practicing psychiatry especially in emergency situations and hospitals, you need to be more practical.  When I took the oral boards exams back in 1988 and subsequently when I was an examiner, one of the key dimensions that the examiners focused on was the assessment of dangerousness.  Failing to explore that could be an exam failing mistake.  Any psychiatric inpatient unit has aggression toward self or others as one of the main reasons for admission to acute care and forensic settings.  With the recent fragmentation and rationing of psychiatric services, many people who would have been treated in hosptials are diverted to jails instead.  That led one author to describe LA County jail as the country's largest psychiatric facility.  

I have introduced the idea of looking for solutions into professional and political forums for over a decade now and it is always met with intense resistance.  Some mental health advocates are threatened by the idea that it will further stigmatize the mentally ill as violent.  Many people consider the problem to be hopeless.  Others see it as the natural product of a heavily armed society and no matter what side you are on that argument - that is where the conversation ends.

In an attempt to reframe the issue so that this impasse could possibly be breached the Minnesota Psychiatric Society partnered with the the Barbara Schneider Foundation and SAVE Minnesota in the wake of a national shooting incident to suggest alternatives.  Rather than speculate about psychiatric disorders or gun control we were focused on solutions that you can read through the link below.

The actual commentary was never published by the editor who apparently stated that there was a conflict of interest because we seemed to be fishing for research dollars.   It appears that the press can only hear the cycle of tragedy, speculation about mental health problems, and the need to move on.  The problem with that is that we continue to move on to another shooting.

George Dawson, MD


A Commentary Statement submitted to the StarTribune January 18, 2011 from the Minnesota Psychiatric Society, The Barbara Schneider Foundation, and SAVE - Suicide Awareness Voices of Education

"The land of 10,000 90862s"

The title of this post is an inside joke for psychiatrists.  90862 is the billing code associated with a psychiatric visit that is commonly referred to as the "med check."  It is an example of what can happen to a profession when government bureaucrats and businesses run amok in determining what they think you do or what you should be doing when you provide patient care.

I first became aware of the political importance of this system in the 1990s, when I had to attend mandatory billing and coding seminars at my place of employment.   In those seminars I learned that the politicians and insurance companies were so desperate to use this arbitrary system that they told us we could go to federal prison for a long time if we submitted a "fraudulent" billing document.  The "fraudulent" document they were talking about was any bill connected to the document of a patient encounter that did not have enough bullet points to qualify for that level of billing.

That is an important concept so let me say it another way.  After every patient encounter, the physician needs to document a note about what happened and indicate a level of billing for that encounter.  When I first started training the note could be as little as one or two lines.  For example, at one point in my training I covered an entire surgical service with a team of doctors.  We could round on 25-30 patients with very complicated problems and write all of the documentation in about 2 hours.  The documentation was "Pain is well controlled, surgical site looks good, vital signs are stable."  We did not have to bother with any billing documents because a hospital billing specialist came by and confirmed that we had seen the patient and submitted the bill.

Somewhere  in the 1990s, a government initiative changed all of that.  The government decided that they needed a way to control the global budget for physician salaries and they decided to develop a system of codes for patient encounters that they assign relative values to and then multiply that by a certain number to set reimbursement for that code.  The entire system rests on the assumption that somebody can look at the description of a patient encounter as written in a note and audit the associated billing document.  It turns out that when this assumption was tested several years later - it was determined to be false, but that did not deter the federal government or the health insurance industry (see reference).

The 90862 is probably the most abused billing code in the psychiatric profession.  The interpretation of what constitutes an encounter that qualifies for this code varies from practice to practice and between organizations.  Patient experience varies from literally talking to a psychiatrist for 5 minutes with the goal of getting a prescription refill to a much richer encounter that includes a discussion of other current problems, additional medical diagnostic discussions and psychological advice.  In some cases, acute medical problems requiring emergency care have been identified in these sessions.  There is no doubt that a considerable amount of gaming occurs on the part of some clinicians and most insurance companies and government payers.

The only gaming possible by the clinician occurs at two levels.  The first is total time spent with the patient.  The folklore is that these are all 15 minute encounters.  Some clinicians insist on seeing patients in half hour blocks and others see 3 - 4 people per hour.  The second is total documentation.  You can literally do a few lines or you can write several paragraphs and stay after work just to do the documentation.  A lot depends on whether you think you will be audited and somebody will be making an arbitrary decision about whether your note qualifies for the charge that you assign to it.

There are myriad ways that a managed care company can game the system.  First of all, they can assign any level of reimbursement to any billing code that they want.  I quoted a New York Times article in another post as saying that a psychiatrist could see three patients for medications and get reimbursed at $50 per session, but the actual reimbursement can be less than half of that.  That same managed care company can also take any bills submitted for patient encounters with higher reimbursement levels and say: "we are only paying you for a 90862 no matter what you do."  If you happen to be working in an institutional setting, a managed care company can negotiate a per diem rate with your employer and not pay the 90862 billing at all.

Stated another way, a psychiatrist can see a patient with complex medical and psychiatric problems and get reimbursed at a level that might lead to them break even - to getting no reimbursement at all depending on the insurance company and contracting arrangements.  Within organizations the relative values for these codes are the basic way that physicians are manipulated to see more patients.  It is referred to as their "productivity" even though producing work for little or no reimbursement is not really productive activity.  The physician managers can demand that they see more and more patients to compensate for the poor or nonexistent rate of reimbursement by managed care companies.

Another artifact of this system is that procedures like surgeries, endoscopies, and angioplasties are reimbursed at a higher rates than a doctor talking with you and discussing the diagnosis and treatment.  That lead to a movement to reimburse the cognitive or nonproceduralist specialties at higher rates.  But given the amount of government payer and insurance company leverage it is impossible to make that happen.

Is there a solution to this problem that in effect makes physicians work impossibly harder to earn a professional salary?  The solution is as easy as considering how I pay my attorney, accountant, mechanic, plumber, electrician, and chimney sweep.  I pay them all by the hour.  In some cases there is an agreed fixed amount, but it is generally many times more than what I would get reimbursed for the lowest 90862 reimbursement.

Getting back to the title of this post, when I looked at the lowest current reimbursement for a 90862 and calculated how many of those bills would need to be submitted to make a professional wage, it came out to about 10,000 patient encounters per year.  Working 50 weeks per year that would mean seeing 40 established patients per day.  The only clinic where I have ever observed those numbers had three nurses rooming the patients and doing all of the documentation before they were briefly seen by a psychiatrist.

As I contemplated all of this I had the thought: "I am living in the 'Land of 10,000 lakes' - maybe we should just change that to the 'Land of 10,000 90862s.' "

George Dawson, MD

King MS, Lipsky MS, Sharp L. Expert agreement in Current Procedural Terminology evaluation and management coding. Arch Intern Med. 2002 Feb 11;162(3):316-20.

90862 Redux? An Update.

Why Do They Hate Us?

The title of this column weighed heavily on the minds of some Americans immediately after the terrorist attacks of 911. I was involved in some Internet forum political debates at the time that looked at this question.  The question itself implies a lack of self analysis and misunderstanding of rhetoric and political strategy. Those same basic concepts can be applied to an analysis of psychiatry and the common political and rhetorical strategies that are used against us.

At this point some readers may suggest that this is quite a tangent for me to take given the fact that psychiatry after all is part of the medical establishment and as such should have very little to complain about.  Four or five decades of complaints from anti-psychiatry cults and about two decades of complaints from competing professionals has done little to diminish the influence of psychiatry.  If that is really the case, why has psychiatry been disproportionately affected in terms of resources available to treat patients and why are psychiatrists blamed for that?  I suggest that the discrimination against psychiatrists and their patients occurs at every level as the direct result of an antipsychiatry bias.

I first came directly in contact with hatred of psychiatrists in an unexpected setting – an academic team rounding on medical surgical patients.  It consisted of an attending, a senior resident, two interns and two medical students.  When the attending learned I was going to do a psychiatric residency, it was an opportunity for ridicule.  Didn’t I realize that psychiatrists were lazy and did not know what they were doing?  Didn’t I know that nobody with a mental health problem should consult with a psychiatrist?  The special attention focused on me peaked when this attending challenged me on the correct diagnosis of acute abdominal pain.  The patient was middle aged, obese and had acute abdominal pain with nonspecific exam findings.  What was my diagnosis?  When I said “appendicitis” – the attending said I was wrong and gave all of the reasons why the diagnosis was cholecystitis.  Several hours post op we had the diagnosis of acute appendicitis.  I learned more about what some physicians think of their psychiatric colleagues than the diagnosis of the acute abdomen during that rotation.

I came across an illuminating piece in the British Journal entitled Advances in Psychiatric Treatment. The author Claire Bithell of the Science Media Center in London showed that psychiatry was less likely to be reported on in the popular press and when it was, received treatment that was four times as negative as other medical specialties.  In an associated piece based on meetings with journalists, academics, clinicians and journalists she found problems at all levels in terms of engaging the media and one of the conclusions was that experts need to engage with breaking news stories to get important messages across to the public.

  

It is easy to prove to yourself that the same problem with the press exists in the US.  It is as easy as going to the New York Times web site and doing a quick search on psychiatry.  The search returns the articles and several commentaries on how psychiatrists are turning to medication management rather than psychotherapy,  an article on how the man accused of the mass shooting at Fort Hood was a psychiatrist, Radovan Karadzic was a psychiatrist, and an article about Carl Jung.  One of the central articles “Talk Doesn’t Pay So Psychiatry Turns Instead To Drug Therapy” gives the specific detail: “A psychiatrist can earn $150 for three 15-minute medication visits compared with $90 for a 45-minute talk therapy session”.  But at that point the author incorrectly concludes that competition from other mental health providers is the reason that psychotherapy is so poorly reimbursed.  He should have just applied his earlier conclusion that the dominance of large hospital groups and corporations in combination with the government essentially fixes insurance reimbursement to whatever the payers want to pay.  They do not want to pay for psychotherapy despite the fact that it is clearly an evidence based therapy.

The origins of bias against psychiatry are varied and include the continued misunderstanding of what we do and what our training is, fear of mental illness, and in many cases the pursuit of political goals.  We have seen attacks on psychiatrists by politicians, Hollywood stars, other psychiatrists, and of course anyone who wants to write an antipsychiatry book.  It can be very subtle such  as recognizing that there is no practical way that psychiatric services can be provided and shutting them down.  In this case it is common to blame psychiatrists for the “lack of access” rather than inconsistent and unrealistic reimbursement by payers.   I was talking to a highly reimbursed proceduralist one day who said that she didn’t mind that some of their margin was used to pay for psychiatry because it seemed like a needed service.

 At times the sheer amount of noise out there about psychiatry is deafening.  I don’t think we are alone when it comes to negative publicity.  Teachers and law enforcement come to mind.  I do not think that there is any doubt that public perception is affected by what is often false information about psychiatry. 

Apart from what is purely propaganda,  most people have an innate tendency to see themselves as armchair psychologists.  Artificial intelligence philosophers came up with the term folk psychology to discuss this tendency and its benefits.  If you are a folk psychologist you might conclude that it is so easy that a psychiatrist has nothing to add, especially when you watch other folk psychologists on television all day long.  Some of the people who have hated us the most have had their theories rejected by organized psychiatry.

From an organizational standpoint,  how do we respond to the hate?  Although it would serve us well,  I doubt the public is very familiar with the philosophical criticisms of folk psychology any more than they know the difference between a psychiatrist and a psychotherapist.  What can we do when we are being smeared on a routine basis?  Ignoring the attacks is a strategy that the APA has used for years.  From a strategic perspective – it is effective to a point.  That point is where some of our detractors gain either political advantage or there are sudden and unexpected changes.  Before that happens we need to be much more aggressive.

Since my early days of involvement with the Minnesota Psychiatric Society,  we have always believed that getting our message out to the public was a critical first step.  I was the Public Affairs Director in the 1990s and coordinated several of the initial National Depression Screening Days.  Today the majority of depressed people I see have been treated for at least 10 years by family physicians and although they were reluctant to see a psychiatrist , they really had no idea that I was a medical specialist.  MPS recently tried to get a letter published by local media on the mass shooting phenomenon.  We co-authored the letter with two mental health public service organizations and it was rejected at a time when there was peak speculation about whether or not the alleged perpetrator was mentally ill and others  were identifying heroes and suggesting that we move on.   Depending only on a biased press is a recipe for continued failure.

We need to start by recognizing that we all have a common interest here and it is called the psychiatric profession.  That is true if you are employed by a health care organization, the government or self employed.  That is true if your job is primarily research, patient care, or administration.  That is true if you are a medical student who has just been accepted to psychiatric residency.  When we are under constant attack – a short term solution is to cut and run.  That will not work in the long run.  We are currently the standard bearers for the kind of care that is possible and apart from our colleagues in other countries we are often shouting alone in the woods.  It is very clear that state and national governments and their allies in the business world do not care about reasonable standards of psychiatric care and in many cases have codified that.  Other advocates are often left to play one side against the other on an artificial playing field of constrained resources.  Psychiatrists have a common interest in making a stand against unfair treatment by both the government and the health care industry.

The other issue is how to make that stand.  We currently have political strategies with politicians and other groups with similar interests.  Those groups are not interested in our standards and we need to take those arguments directly to the public.  We have to let them know what inpatient units and state hospitals are capable of doing.  We need to let them know what state of the art community psychiatry looks like.  We have to let them know that outpatient psychotherapy for depression is actually more than a session or two and coming back every month or two to see somebody about medications.  We have to speak out on every topic of mental health interest in the media and presenting it ourselves rather than expecting the media to pick it up.  That is our job in the near future.

That is also in part what this blog is all about.

Is it the economy?

The lead story in this week's Psychiatric Times was sent to me in e-mail this morning under the subject "Economy Threatens Psychiatry Programs". It provides the news that the Cedars-Sinai Department of Psychiatry and Behavioral Neurosciences is essentially being phased out except for "staffing of psychiatric support that is an adjunct to patient care throughout the medical center." It quotes an unnamed academic psychiatrist as saying that the real reason that psychiatric programs are getting the axe is that they are the least profitable services offered at any hospital. The article goes on to suggest that declining Medicare funding of Graduate Medical Education may threaten additional programs.

The only real explanation and dose of reality in that article was the quote from their anonymous source. Psychiatric programs and bed capacity have been closing down for the past 20 years. It is the direct product of managed care strategies either being applied directly by the managed care cartel or through their friends and allies in the government. I have previously posted on this blog how psychiatric services have been marginalized from an economic standpoint.  That should be obvious from surveying any acute care hospitals in your state. In the state of Minnesota for example, a minority of the total hospitals have psychiatric units and fewer are staffed for chemical dependency services.  That has resulted in the need to transfer patients in crisis in emergency departments across the state or in some cases in different states. As a result any involved family members have to travel hundreds of miles to maintain contact with that person.  The economy for psychiatry has been bad for the last 20 years.

The evolution of this process is apparently so insidious that nobody pays attention to it. The only way that the minority of hospitals with psychiatric units can continue to operate and staff those units with psychiatrists is if they do a high volume, low quality DRG based business or they are subsidized to some degree out of the profit margin of other departments. In that case, an economic argument can be made that more severely ill psychiatric patients or medically ill psychiatric patients would never leave medical or surgical units if there were not psychiatric units available to receive them in transfer.

This process is easily reversed by providing adequate compensation for psychiatric care. The reimbursement levels for inpatient care are so trivial that an inpatient psychiatric unit is currently the least expensive place to maintain the patient.  At some point, treatment on a DRG based inpatient unit is cheaper than a group home and much cheaper than a state hospital.  That creates additional incentives and barriers to discharge from the hospital.

The bottom line is that it is not the economy.  There has been a systematic bias against mental health services for at least 20 years.  It is well past the time for psychiatrists and other advocates to remove the term "cost effective" from their dialogue. Psychiatric and mental health services have been the most cost effective medical services for at least the past 20 years and there is no reason for expecting them to get less expensive. Reversing that trend and providing compensation that is at least on par with the rest of medicine will allow for quality psychiatric hospital services and outpatient clinics.

George Dawson, MD

Stephen Barlas. Elimination of Psych Services at Cedars-Sinai Could Foreshadow Similar Cutbacks Elsewhere.  Psychiatric Times Vol 29, No2, February 8, 2012 

Endnote:  According to the Minnesota Hospital Association 29 of 136 acute care hospitals have beds staffed for mental health care and 6 of 136 have beds staffed for chemical dependency care.

Managed Care 101 – The Prior Authorization Hoax

As managed care organizations worked on how they could prioritize pricing over medical decisions they came up with various plans to “manage” how physicians prescribed medications.  I was a member of two Pharmacy and Therapeutics Committees (P & T) that  both had this as a goal.  One of those committees had a much stricter mandate in terms of saving money.  The basic strategy used by that committee was to place a drug “on formulary” or “off formulary”.  If it was “off formulary” it was not available to any doctors within the HMO to prescribe.

The idea that all drugs within a class that had the same purported mechanism of action ruled the day.  As an example, all of the selective serotonin reuptake inhibitors (fluoxetine, paroxetine, sertraline, citalopram, escitalopram, fluvoxamine) would be considered equivalent medications and the committee would decide to place the least expensive ones on the formulary.  At the time, the major controversy was fluoxetine because there was no generic brand available and the company that produced it was notorious for not negotiating prices with hospitals and health care systems.  There was an eventual appeal by psychiatrists who presented to the committee on the unique qualities of fluoxetine.  At the time it was the only medication studied in adolescent depression for example.  Eventually a rule was passed that it was nonformulary for any physician who was not a psychiatrist.

The total cost of the drug was more of a consideration than the absolute price.  Very expensive drugs were approved that had questionable endpoints based on the fact that utilization would be low and that advocates for a particular untreatable illness would want it.  So the decision of the committee and their mandate was to reduce the use of relatively more expensive drugs that would be used fairly frequently.  In some cases, the off formulary drugs were available by “prior authorization” meaning that the prescribing physician needed to usually write up an appeal and fax it to the pharmacy or health plan and in some cases make additional calls.

The health care business has a long history of introducing layers and layers of management driven largely by the amount of money involved.  If you can successfully insert more management for even a small percentage of the available health care dollars you will potentially have a multi billion dollar business.   The management of pharmaceuticals is no exception and the Pharmacy Benefit Manager or PBM was born.  The task of the PBM like the task of a P & T Committee is to control the prescribing physician and force them to choose a medication based on the lowest cost.  Individual variation between patients and all of the other variables that physicians have to take into account do not matter.  If the physician or the patient thinks that they do – it will take a prior authorization for the alternate medication.  

The PBM model was designed from the outset to take a central role in the management of prescription drugs by replacing the relationship that the patient has with their health plan, their pharmacist, and even their physician.  How do I know this?  Take a look at their game plan from an internal memo in the diagram below.  This diagram was taken from an internal memo from over 15 years ago.  The structure depicted in the diagram is the system of care that exists today and the one that 95% of patient have their benefits managed through 

The prior authorization fallacy is essentially the same as the utilization review fallacy.  The most charitable interpretation is that it assumes that a person who is not necessarily a physician and who has no personal responsibility for your care can substitute their judgment based on a cost consideration.    

The diagram is also instructive in the way that the prescribing decision (and the dispensing decision) is trivialized as a "habit" rather than a decision that takes into account the evaluation and personal knowledge of the individual patient.

Today all physicians are routinely subjected to prior authorization procedures that waste significant amounts of their time and the time of their staff in order to make seem like the PBM decision has some degree of medical legitimacy.  The cost to medical practices is huge and completely unnecessary.  If PBMs are really businesses there is really no legitimate reason that they need to include physicians in their decisions of what medication should be covered.  They just need to plainly state that to their patients and deal with the public relations problems instead of wasting about one million hours of physician time per week.  In the weeks that follow I will demonstrate just how far this business plan has infiltrated medicine and psychiatry and what the response has been to date.

George Dawson, MD

Critical Article on the Efficacy of Psychiatric Medication

There is a seminal article in this month’s British Journal of Psychiatry by Leucht, Hierl, Kissling, Dold, and Davis.  The authors did some heavy lifting in the analysis of 6175 Medline abstracts and 1830 Cochrane reviews to eventually compare 94 meta-analyses of 48 drugs in 20 medical diseases and 33 meta-analyses of 16 drugs in 8 psychiatric disorders.  The authors have produced a graphic comparing the Standard mean difference of effect sizes between the general medicine drugs and the psychiatric drugs.  It is apparent from that graphic that the psychiatric drugs are well within the range of efficacies of the general medical drugs.

This is an outstanding study that merits reading on several levels.  The authors have used state of the art approaches to meta-analysis following suggested conventions.  They provide the summary of the studies reviewed and actual details of their calculations in the accompanying tables. (the document including references and PRISMA diagrams is 59 pages long.)  They have a comparison of standard criticisms of psychiatric drugs and illustrate how the criticisms are not fair and the toxicity considerations are often greater in the general medicine drugs than the psychiatric drugs. 

This paper should be read by all psychiatrists since it is an excellent illustration of an approach to large scale data analysis using modern statistical techniques.  It is a good example of the application of the discussion by Ghaemi of hypothesis testing statistics versus effect estimation.  The authors also have an awareness of the limitations of statistics that the detractors of psychiatric care seem to lack.  Their statements are qualified but they provide the appropriate context for decision making about these medications and the implication is that decision matrix is clearly squarely in the realm of other medical treatments in medicine.

From the standpoint of the media and the associated politics it will also be interesting to see if this article gets coverage relative to the articles that have been extremely critical of psychiatric drugs.  I can say that I have provided the link to the article by Davis, et al on the issue of antidepressant effectiveness to several journalists including the New York Times and it was ignored.  The press clearly only wants to tell the story against antidepressants and psychiatric medications.

Never let it be said that any aspect of psychiatric treatment gets objective coverage in the press.  That problem and the lack of investigation of that problem is so glaring at this point that the press lacks credibility in any discussion of psychiatric treatment.

George Dawson, MD

Leucht S, Hierl S, Kissling W, Dold M, Davis JM. Putting the efficacy of psychiatric and general medicine medication into perspective:review of meta-analyses. Br J Psychiatry. 2012 Feb;200:97-106. PubMed PMID: 22297588

S. Nassir Ghaemi (2009) A Clinician’s Guide to Statistics and Epidemiology in Mental Health: Measuring Truth and Uncertainty.  Cambridge University Press, New York.

Davis JM, Giakas WJ, Qu J, Prasad P, Leucht S. Should we treat depression with drugs or psychological interventions? A reply to Ioannidis. Philos Ethics Humanit Med. 2011 May 10;6:8.

Seemuller F, Moller HJ, Dittmann S, Musil R. Is the efficacy of psychopharmacological drugs comparable to the efficacy of general medicine medication? BMC Med. 2012 Feb 15;10(1):17. Free full text commentary on the main article from another journal    -      download the pdf.

Managed Care 101 – The Utilization Review Hoax

I happened to start practicing psychiatry at a time when managed care was just starting to build momentum. From a political standpoint there was concern in the popular press that healthcare services were being over utilized. There is a famous study by the RAND Corporation looking into whether or not angiography and bypass surgery were being used to frequently to treat cardiovascular disease. There was a concern that medical and surgical procedures in general were being over utilized. This was part of the driving force for a large scale experiment called the Medicare PRO or Peer Review Organizations.

In the late 1980s and throughout much of the 1990s I was a physician reviewer for the Medicare PROs, first in Wisconsin and then in Minnesota. My job was to look at cases selected from all psychiatric hospitalizations in the state and determine whether the total length of time in the hospital was appropriate for the condition and whether or not there were any associated quality problems. There was an extensive list of quality problems that nurse reviewers would identify and forward to me for further assessment. Examples of quality problems ranged from death on a psychiatric unit to abnormal vital signs at the time of discharge to the appropriate monitoring of the therapy like lithium that require close monitoring. All physician reviewers working for this organization had to be carefully screened for conflicts of interest.  I could not review any case if I had any financial interest in the hospital or clinic where the incident occurred.

At about the same time managed care companies were establishing utilization reviewers for their insured members. They had no quality focus or quality markers. Their only focus was whether or not one of their members was entitled to inpatient coverage or a specific course of outpatient therapy. There were no conflict of interest considerations because the reviewers were all paid by the managed care company and therefore their financial interests were aligned with the corporation.

You could consider the two different forms of utilization review to be the great experiments in the provision of medical care in the 1990s. More appropriately the Medicare PROs were probably the experimental side and the managed care utilization reviewers represented a business model that really required no experimentation. It seemed quite obvious that if you could deny care that you would make more money.  What happened to these two models over the next 10 years?

Despite the rigorous screening and structurally defined quality problems used by the Medicare PRO, at one point it was determined that the amount of over utilization found in the state of Minnesota was not enough to justify the cost of the program. After all of the hype in the press about how physicians and hospitals were providing unnecessary care, that was a stunning finding on such a large scale that it should not have been ignored. It essentially meant that from an objective scientific standpoint utilization review is unnecessary. Minnesota stopped its utilization effort and decided to partner on the quality side with health care organizations to improve the treatment of specific conditions.

Utilization review on the managed-care side has not only continued but flourishes despite the fact that there is no objective basis for it and that managed care organizations have complete control over reimbursement to physicians and hospitals and the reimbursement for psychiatric services is the absolute lowest.  The most recent development has been internalizing utilization review directly into the hospital and using care managers to force discharges from hospitals. These care managers often depend on a quasi-scientific set of guidelines or standards that frequently ignore the specific needs of patients

.

Psychiatry has been hit particularly hard by this quasi-quality approach that disproportionately rations care to psychiatric patients. We are currently seeing people with complex disorders like unstable bipolar disorder discharged from psychiatric hospital within a few days because the "crisis" is over and yet they are not able to function by themselves at home. We have allowed managed care organizations to essentially dictate a standard that suggests the only reason that a person should be a psychiatric unit is if they are "suicidal" or a threat to others.  There is broad interpretation of what "suicidal" means and of course the physician reviewer for the insurance company has never personally assessed the patient or their circumstances.  The vast majority of patients who would benefit from quality care in a hospital would not meet either of those criteria and frequently have no other resources.

The fallout from this approach has been tremendous. Psychiatric care in hospital settings is generally viewed as being very poor in quality. Many outpatient psychiatrists I have consulted with have told me that there is essentially no place that their unstable outpatients can be stabilized because they are frequently discharged from hospitals in a few days and the treatment has not been changed. There is little collaboration between inpatient and outpatient psychiatrists because of the need for high turnaround and the time constraints.  The actual inpatient environments are frequently so toxic that people with fairly severe problems don't want to be there.  Managed care is focused primarily on providing high-volume, low quality care by the application of a method that has no basis in reality.

Antidepressants - the limited analysis of a polarized argument

The current President John Oldham and President-elect Jeffrey Lieberman of the American Psychiatric Association came out with this press release today on a 60 Minutes episode characterizing antidepressants as no better than placebo.  They describe this characterization as “irresponsible and dangerous reporting” and “a message that could potentially cause suffering and harm to patients with mood disorders.”

It is good to see the APA finally taking a stand on this issue.  Antidepressants and the psychiatrists who prescribe them have been taking a pounding in the popular press for years.  The main proponent here was also featured in a Newsweek headline story two years ago.  This is a prototypical example of how the media and special interest groups can distort science and facts and politicize the discussion that must be nuanced.  The problem is that you have to know something and be fairly free of bias to participate in a nuanced discussion.  Like most issues pertaining to psychiatry, the issue is always polarized and poorly discussed in the media.

I got involved in this issue as a managing editor of an Internet journal and I solicited a paper from a world renowned epidemiologist to get his current view on antidepressant meta-analyses. In order to present the entire argument I also solicited response from a world renowned psychopharmacologist with broad expertise in this field. Both articles are available online for free and I think if they are both read in total they represent the most accurate picture of antidepressant response.  Both references are listed at the bottom of this page.

Rather than get into the specific details at this point I will say that it was extremely difficult to find a anyone willing to provide a rebuttal to the to the original article by Ioannidis, but anyone who reads that paper by Davis, et al and who follows the antidepressant literature will have a greater appreciation of the effectiveness of these medications.  I hope to post some information on the statistical analysis as well.  At some level people tend to view statistics as a hard mathematical science and there is plenty of room for interpretation.  The use of meta-analysis is a common approach to these problems and a detailed look at the shortcomings of meta-analysis are seldom discussed.  That might explain why one meta-analysis shows minimal effects and another shows that there might be some antidepressants with unique effectiveness (see Cipriani, et al)

A final dimension that is critical in the analysis of any source is potential conflicts of interest.  The only conflict of interest that is typically discussed is the financial interests of authors and pharmaceutical companies in producing positive trials.  That ignores the fact that many of these trials have been very public failures and that post trial surveillance limits the use of some of these compounds.  There are other conflicts of interest to consider when an author is selling a viewpoint and can potentially profit from it – either financially or politically.

The APA could provide a valuable service here in making the documents from the FDA and the EMA widely available for public discussion and analysis.

George Dawson, MD

 “60 Minutes” Segment on Antidepressants "Irresponsible and Dangerous" – APA New release Febrary 22, 2012.

Ioannidis JP. Effectiveness of antidepressants: an evidence myth constructed

from a thousand randomized trials? Philos Ethics Humanit Med. 2008 May 27;3:14.

Davis JM, Giakas WJ, Qu J, Prasad P, Leucht S. Should we treat depression with drugs or psychological interventions? A reply to Ioannidis. Philos Ethics Humanit Med. 2011 May 10;6:8.

Cipriani A, Furukawa TA, Salanti G, Geddes JR, et al.  Comparative efficacy and acceptability of 12 new-generation antidepressants: a multiple-treatments meta-analysis.  The Lancet - 28 February 2009 ( Vol. 373, Issue 9665, Pages 746-758 )