Another Managed Care Approach Bites the Dust

Managed care companies have always been big on patient satisfaction.  There are a number of reasons for this the largest one being that they hope to replace medical approaches to healthcare with business approaches. That involves applying paradigms used in automobile manufacturing and customer service such as patient satisfaction surveys. It also involves applying business strategies to those surveys so that any particular business will look as good as possible when it is advertised. It is no accident for example that all the hospitals in your area are "five-star hospitals" or "highly rated" if the companies involved know how to game the system, the deck is stacked in favor of high patient satisfaction ratings. That can be done by combination of survey structure, survey timing, or scripting. During scripting the patient is exposed to a number of statements by a healthcare provider who has been trained in how to do this so that their statements closely match questions on the patient satisfaction survey. It is very difficult for a person to say they were never provided with information if they received carefully scripted information five minutes before they took the survey.

Another advantage of patient satisfaction surveys is that they can be used as leverage against physicians. Managed care companies are always on the lookout for new ways they can reduce reimbursement to physicians. They already have an incredible amount of leverage with the so-called RVU-based compensation system but apparently that is not enough.  In many cases a percentage of the physicians reimbursement is linked to patient satisfaction surveys. The more satisfaction, the greater the reimbursement. The irony is that in many cases, the money used for that incentive is a "hold back" or percentage of what the physician has actually earned. They will not get their full reimbursement unless they have adequate patient satisfaction ratings. The problem with that system should be obvious, but it was made even more obvious by a recent article in the Archives of Internal Medicine.

In that study, the authors looked at a large sample of 51,947 patients over a timeframe of seven years. They focused on how their satisfaction ratings correlated with outcome measures. They found that the patients in the high satisfaction group had a 8.1% greater healthcare expenditure, 9.1% greater medication expenditure, and a 26% greater mortality risk.  The most satisfied group was at less risk for an emergency department visit but had higher inpatient expenditures.  The authors point out that patient satisfaction ratings correlate most highly with whether or not the physician fulfills the expectations of the patient.  That could lead to a lower threshold for elective admissions to hospitals, more invasive testing, and less discriminatory prescribing practices.

Their overall conclusion is that we do not know enough about patient satisfaction ratings and the implications for quality care. They make an excellent point about the need for physicians to discuss problem areas with patients “including substance abuse, psychiatric comorbidity, nonadherence, and the risks of requested but discretionary tests or treatments.”  Those discussions may not be conducive to high patient satisfaction ratings.  They also point out that these discussions necessarily take time. As I have previously pointed out, the time for discussions and clinics has practically been rationed out of existence.

I thought that this was an excellent article overall that points out significant problems with business approaches to the practice of medicine. Rating a doctor like you would rate your car salesman creates a unique set of problems that businesses and the government have no interest in addressing.  Ratings within healthcare organizations linked to physician "incentives" may be no more reliable than doctor ratings on Internet sites.

George Dawson, MD

Fenton JJ, Jerant AF, Bertakis KD, Franks P. The cost of satisfaction: a national study of patient satisfaction, health care utilization, expenditures,and mortality. Arch Intern Med. 2012 Mar 12;172(5):405-11.

Mad Men scene

The scene between characters Don Draper and Peggy Olson in AMC TVs award winning show Mad Men (as in Madison Avenue) has an excellent bit of advice that I have tried to impart at times.  In this scene, Peggy is in what appears to be a psychiatric hospital and she is bedridden. She has just gone through a major life crisis and tried to conceal her whereabouts from her boss Don Draper. Prior to this crisis she had impressed Draper to the point that he promoted her and he brings that up during this conversation.

Draper on the other hand, had a similar life crisis when he was in his early 20s that involved changing his identity to the identity of a soldier he was serving with during the Korean War. He has a significant amount of psychological trauma from his childhood. His advice in this scene captures the way he has dealt with his own problems but also captures a larger thread of developmental psychology and speaks to the fact that as we deal with more crises through our lives it affects us less and and we can recover from it more quickly. That basic concept of resilience is not talked about enough in assisting people with crises in their lives.

Psychiatrists work for patients - not for pharmaceutical companies

That should be obvious by anybody reading this post but it clearly is not. I have already established that there is a disproportionate amount of criticism of psychiatry in the popular media compared with any other medical specialty. The most common assumption of most of those critics is that psychiatrists are easily influenced by pharmaceutical companies or thought leaders who are working for pharmaceutical companies. There are many reasons why that assumption is incorrect but today I want to deal with a more implicit assumption that is that there is a drug that is indicated and effective for every medical condition.

In the field of psychiatry this marketing strategy for pharmaceuticals became prominent with the biological psychiatry movement in the 1980s. Biological psychiatrists studied neuropsychopharmacology and it followed that they wanted to apply their pharmaceuticals to treat human conditions. At the popular level initiatives like National Depression Screening Day were heavily underwritten by pharmaceutical companies and the implicit connection was that you could be screened and be treated with a medication that would take care of your depression.

From the perspective of a pharmaceutical company this is marketing genius. You are essentially packaging a disease cure in a pill and suggesting that anyone with a diagnosis who takes it will be cured. The other aspects of marketing genius include the idea that you can be "screened" or minimally assessed and take the cure. We now have the diagnosis, treatment, and cure neatly packaged in a patent protected pill that the patient must take.  The role of the physician is completely minimized because the pharmaceutical company is essentially saying we have all the expertise that you need. The physician's role is further compromised by the pharmaceutical benefit manager saying that they know more about which pill to prescribe for particular condition than the physician does. That is an incredible amount of leverage in the health care system and like most political dimensions in healthcare it is completely inaccurate.

The pharmaceutical company perspective is also entirely alien to the way that psychiatrists are trained about how to evaluate and treat depression.  Physicians in general are taught a lot about human interaction as early as the first year in medical school and that training intensifies during psychiatric residency. The competencies required to assess and treat depression are well described in the APA guidelines that are available online.  A review of the table of contents of this document illustrates the general competencies required to treat depression. Reading through the text of the psychopharmacology section is a good indication of the complexity of treating depression with medications especially attending to side effects and complications of treatment and decisions on when to start, stop, and modify treatment. Those sections also show that psychopharmacology is not the simple act that is portrayed in the media. It actually takes a lot of technical skill and experience.  There really is no simple screening procedure leading to a medication that is uniformly curative and safe for a specific person.

The marketing aspects of these medications often create the illusion that self-diagnosis or diagnosis by nonexperts is sufficient and possible. Some people end up going to the website of a pharmaceutical company and taking a very crude screening evaluation and concluding that they have bipolar disorder. In the past year, I was contacted by an employer who was concerned about the fact that her employee had seen a nonpsychiatrist and within 20 minutes was diagnosed with bipolar disorder and treated with a mood stabilizer, an antidepressant, and an antipsychotic medication. Her concern was that the employee in question could no longer function at work and there was no follow-up scheduled with the non-psychiatrist who had prescribed medication.  Managed care approaches screening patients in primary care settings increase the likelihood that these situations will occur.

The current anti-psychiatry industry prefers to have the public believe that psychiatrists and their professional organization are in active collusion with the pharmaceutical industry to prescribe the most expensive medications.  In the case of the approximately 30 antidepressants out there, most are generic and can be easily purchased out-of-pocket.  Only the myth that medications treat depression rather than psychiatrists keeps that line of rhetoric going.

George Dawson, MD

American Psychiatric Association.  Practice Guideline for the Treatment ofPatients With Major Depressive Disorder, Third Edition. 2010

Wartime atrocities

The recent mass murders in Afghanistan and the analysis of the events in the press highlight my contention from an earlier post that the press really does not do a good job in these situations. We can expect a continued exhaustive risk factor analysis and discussions by various pundits. The accused soldier clearly had a lot of exposure to combat stress, there is a history of traumatic brain injury, there is a possible history of substance abuse, and there are multiple psychosocial factors. So far we have seen the statements by people who knew him describing this event as completely unpredictable based on his past behavior. The debate will become more polarized as the lawyers get involved. The real truth of the matter is never stated.

What we know about these incidents is more accurately described by anthropologists than psychiatrists or psychologists. The best book written on this subject is Lawrence Keeley’s War Before Civilization.  In that book Dr. Keeley explores the contention that primitive peoples were inherently peaceful compared to modern man and a warfare that was waged was brief, fairly nonlethal, and stereotypic. In order to explore that theory, Dr. Keeley ends up writing a fairly definitive book on the anthropology of warfare. There are more lessons in that book about war and peace then you will ever hear on CNN or in the risk factor analysis that is produced in the popular media.

So what do we know about the mass murder of civilians during warfare? The first thing we know is that it is commonplace. It happens in every war and no military force despite their level of training is immune to it.  In prehistoric times, the most frequent scenario was a surprise attack on a village with the goal of killing as many inhabitants as possible. In Keeley's review, that number was generally around 10% of the population and that could have devastating consequences for a particular tribe including the complete dissolution.

Keeley also makes the point that: “Only the "rules of war," cultural expectations, and tribal or national loyalties make it possible to distinguish between legitimate warfare and atrocities.”  He gives the examples of Wounded Knee and My Lai as well as larger scale bombings of Hiroshima and Dresden.  My Lai was a highly publicized incident from my youth. It occurred during the Vietnam War when the US Army massacred hundreds of Vietnamese noncombatants – largely women, children, and old men.  In that situation, 26 soldiers were charged and only one was convicted. The convicted soldier served 3 1/2 years under house arrest.

In addition to outright killing, mutilations of bodies and the taking of body parts as trophies continue to occur in modern civilized warfare in much the same way that these practices occurred in primitive warfare.  Haley reported on a series of Vietnam veterans seen in psychotherapy and the special problems that exist in patients who have been exposed to or participated in wartime atrocities. Based on the literature at the time she suggested that the war in Vietnam resulted in a disproportionate number of atrocities.

My current final analysis of the situation is that there are important social and cultural determinants of war and the inevitable wartime atrocities. Risk factor analysis and analysis of individual biology is very unlikely to provide an explanation for what occurred. The moral, legal, and political environment has changed since Vietnam and that is obviously not a deterrent. A comparison of the final legal charges and penalties in this case with what happened in Vietnam will be instructive in terms of just how far those changes come. If there is a conviction, there will be a lot of pressure to portray the convicted soldier as very atypical and probably as a person who underwent a significant transformation of his conscious state.  There will be many theories. The idea that this transformation predictably occurs during warfare will not be discussed. I have already heard some experts talking about the thousands of soldiers who go though similar situations and seem to do just fine.

The best approach to these events is a preventive one that includes minimizing the exposure to war instead of being involved in the longest war in American history.  I don't expect that much will be said about that either.

George Dawson, MD

Lawrence H. Keeley. War Before Civilization. Oxford University Press, 1997.

Haley SA. When the patient reports atrocities. Specific treatment considerations of the Vietnam veteran. Arch Gen Psychiatry. 1974 Feb;30(2):191-6.

No Time to Heal

I sent an e-mail to one of my colleagues last night about a bill introduced in the state of Minnesota that would potentially allow managed care companies to replace inpatient psychiatrists with nonphysicians. She thought that was consistent with the managed-care model of high volume and low quality inpatient treatment. She also reminded me of the concept that inpatient units used to be a place where people came to heal. Over the years that I worked in inpatient settings it is apparent that severe psychiatric disorders take their toll and it takes a lot to recover.  Many people are admitted with acute hypertension, dehydration, malnutrition and weight loss, tachycardia, acute blood loss, and any number of stressful physical conditions in addition to their primary psychiatric diagnosis. At least half of the patients admitted to the acute psychiatric inpatient units have been using alcohol, cocaine, or other intoxicants that worsen their physiological state. In some cases such as catatonia, the psychiatric illness alone is life-threatening.  Before there were effective treatments some forms of catatonia had an 85% mortality rate.

Not too long ago when we had more functional inpatient treatment people had time to recover. It was not uncommon to see patients with bipolar disorder take at least 2 to 4 weeks to recover from an acute episode. Inpatient psychiatrists and nursing staffs were experts in supportive care and patience invariably left the hospital in much better condition than they came in.  That is no longer the case. Today the artificial pressure to make money restricts inpatient care to a number of days rather than weeks. That is well below the time frame that it takes for any of the known psychiatric medications to actually work. In the case of the patient with mental illness and substance abuse disorder, they may have only completed detoxification stage by the day of discharge. They leave the hospital in only slightly better shape than they came in.  In many cases, their families were trying to assist them prior to admission and they discovered they could not help.

I don't think that there should be any mistake that the current system is driven strictly by cash flow and the cash flow to psychiatry has always been limited. The business of managed care companies is not to give patients with severe psychiatric disorders the time they need to heal. The business of managed care companies is to make money and use any rationalization along the way to do that. Those currently include the idea that you should only be on an inpatient unit if you are acutely suicidal or aggressive.  The other consideration is that the inpatient atmosphere should not be designed with patient comfort in mind, because we all know that if is too comfortable - somebody might want to stay longer than the system wants them to.

George Dawson, MD

The Day the Quality Died

I don't know when it happened exactly but if I had to guess it was somewhere in the mid-1990's.  That was the time when quality changed from a medically driven dimension to a business and public relations venture. The prototypical example was this depression guideline promulgated by AHCPR or the  Agency for Health Care Policy and Research.  The guideline was written by experts in the field and there was consensus that it was a high quality approach to treating depression in primary care settings. One of my colleagues used this guideline in its original form to teach family practice residents for years about how to treat depression in their outpatient clinics. The actual treatment algorithm is listed below:

Managed care companies had a different idea about treating depression not only in primary care settings but also in psychiatric clinics. In less than a decade the standard of care had devolved to the point where antidepressants were started on the initial visit and the standard outpatient follow-up was at one month. In addition, even though cognitive behavioral therapy was proven to be effective for the treatment of depression the standard course recommended in those research studies was never used. It was common then and even more common now for depressed patients to see a therapist and be told that they seem to be doing well after two or three sessions and there is probably no need for further psychotherapy. They typically did not receive the research proven approach.

The latest innovation is to assess and treat depression in outpatient clinics on the basis of a PHQ-9 score, and have psychiatrists follow those scores and additional information from a case manager in recommending alterations in therapy for patients with depression.  Although it was never designed to be a diagnostic or outcome measure the PHQ-9 is used for both.

The current model of maximizing medical treatment of depression in managed care clinics is an interesting counterpoint to psychiatrists bearing the brunt of criticism for over treating depression with ineffective antidepressants. The recent FDA warning about prolonged QTc syndrome from citalopram is another variable that suggests there are potential problems in maximizing antidepressant exposure across a primary care population where the number of people responding to psychotherapy alone is not known but probably significant.

There is another aspect of treating depression in primary care clinics that illustrates what happens when you think you are treating a population of people with depression. The new emphasis by politicians and managed care companies is screening for early identification of problems. The political spin on that is early intervention will reduce problem severity and of course save money.  Various strategies have been proposed for screening primary care populations for depression. It reminds me of the initiative to ask everyone about whether or not they have pain when their chief complaint has nothing to do with pain.

In the Canadian Medical Journal earlier this year, Thombs, et al, concluded that the evidence screening is beneficial and the benefit outweighs the potential harm is currently lacking and that study should be done before depression screening in primary care clinics is recommended. A recent op-ed by H. Gilbert Welch, M.D. in the New York Times is more accessible in the discussion of the risks of screening.

The irony of these approaches to depression in primary care clinics can only be ignored if the constant drumbeat of managed care companies about how they are going to save money and improve the quality of care is ignored. Despite the frequently used buzzword of "evidence-based medicine" this has nothing to do with evidence at all. It is all smoke, mirrors and public relations.  It makes it seem like managed care companies can keep you healthy when in fact they have all they can do to treat the sick and make a profit.

That is the true end result when medical quality dies and politicians and public relations takes over.

George Dawson, MD, DFAPA

Thombs BD, Coyne JC, Cuijpers P, de Jonge P, Gilbody S, Ioannidis JP, Johnson BT, Patten SB, Turner EH, Ziegelstein RC. Rethinking recommendations for screening for depression in primary care. CMAJ. 2012 Mar 6;184(4):413-8.

H. Gilbert Welch.  If You Feel O.K., Maybe You Are O.K.  NY Times February 27,2012.

Parallel Blog

I have created a second blog that is more concerned with the technical issues of how to produce clinically and educationally useful graphics and the associated issues.  The new blog is at: http://gdpsychtech.blogspot.com/2012/03/why-this-blog.html

 Please send me your ideas and graphics if you like so that I can present them here.  My general plan is to:

1.  Post the graphics and how they were produced as well as commentaries on the learning curve to use the relevant software.

2.  Discuss issues relevant to using copyright material including slides that are now common in electronic journals.

I am sure that more issues will crop up along the way.

George Dawson, MD, DFAPA