The Dog Quadrant

Before anyone gets the wrong idea, this post is not about pet therapy.  It is not about the purported advantages of owning a dog.  It is not even about the new research on dog intelligence that I was frankly surprised by, especially the research showing how easily dogs can beat non-human primates on specific tasks.  So much for that massive frontal cortex conferring supreme advantage over the animal kingdom.  No - this is about managed care and using the term "dog" in its pejorative context.

Several years ago, I was burned out and suffering from the type of large scale mismanagement that is so common in organizations that run on managed care principles.  I attempted to approach the problem with humor by reading Dilbert cartoons.  Read the first few pages in the Dogbert Management Handout to see what I mean. I soon realized that this stuff was too close to the truth about health care management and decided to look for other management styles.

I happened across the work of Peter Drucker and his ideas about managing knowledge workers that were considered revolutionary.  There was certainly nothing like that going on in health care.  The managed care approach to managing physicians was to actually treat them like they were not knowledge workers but assembly line workers.  Drucker's stroke of genius was in recognizing that managers know much less about products and processes than knowledge workers and that the business was essentially the product of the knowledge workers.  Managed care techniques are diametrically opposed and are based on the fact that business guidelines are somehow relevant to medical care and even may actually be called medical quality.  There is no health care process more autocratic and primitive than managed care. I have reviewed how this bizarre set of circumstances evolved in several posts on this blog.

Along the way, I also interviewed a health care business management expert and asked him if there were any definitive texts that are used to train business people about managing health care and he referred me to the text Strategic Management of Health Care Organizations.   I started to read and study the text, initially trying to find out why Drucker was completely ignored by health care managers.  That was when I encountered the BCG Analysis for a Health Care Institution (p 254).   BCG is an abbreviation for Boston Consulting Group who came up with this technique for analyzing products and services.  In this case, there was a four quadrant graph that differences in market growth rate and relative market share position.  I don't have permission to reproduce it here so I will do my best to describe it briefly.  The high growth/high market share quadrant was termed "Stars" and contained services like orthopedics, cardiology, oncology, and women's service.  The medium/high and high/low quadrants were called "Cash Cows" and "Problem Children".  The lower right hand quadrant of the graphic were the "Dogs" and they included psychiatry, ENT, pediatrics and others.

I am no financial analyst, but what is wrong with this picture?  Let me give you a hint.  If you have a portfolio of medical services and one of them is selected for rationing and the others are not - it should easily end up in the Dog quadrant.  The selective rationing of psychiatric and mental health services is a known fact for the last 30 years.  When you ration a service you naturally slow its growth and reduce the market share.  The market share is reduced even more precipitously when you start shutting down bed capacity and hospitals.  Early in the course of all of these events some high profile teaching units in hospitals affiliated with prestigious medical schools were shut down and it was described as being secondary to a lack of reimbursement from companies using managed care models.  If you are in a business that severely distorts the market by controlling growth and market share it makes little sense to pretend that you can analyze portfolios across an imaginary market and make decisions about resource allocation in an organization.

If you were a physician unlucky enough to be trapped in this process it played out in several ways.  There were endless meetings that formed the base of misinformation.  There was the suggestion that productivity was the only fair way to reimburse physicians and the implication that some physicians were much less productive than others.  That was a good way to provoke the competitive, even though in practically all cases that was not true.  Then there was the usual barrage of financial information.  Overhead figures from who knows where.  The suggestion that physicians may need to cover the salaries of any physician assistants working with them.  It was an unending painful process designed to give the appearance that physicians had a say in the business, except at every critical decision they did not.  In the end all there were was a long series of Dogbert management PowerPoints.

I have not seen the latest edition of the book and I wonder if there have been any additional pejorative classifications for mental health or psychiatry.  One thing is for sure.  You don't end up in the Dog quadrant because of lack of real demand or free markets.  You end up in the Dog quadrant because of managed care and their supporters in the government.

And then they can use this analysis to remove even more resources.

George Dawson, MD, DFAPA

Psychotherapy Has No Image Problem - Psychotherapy Has a Managed Care Problem

There was an opinion piece in the New York Times a few days ago entitled "Psychotherapy's Image Problem".  The author goes on to suggest that despite empirical evidence of effectiveness and a recent study showing a patient preference for psychotherapy - it appears to be in decline.  He jumps to the conclusion that this is due to an image problem, namely that primary care physicians, insurers, and therapists are unaware of the empirical data.  That leads to a lack of referrals and for some therapists use of therapies that are not evidence based - further degrading the field.  He implicates Big Pharma in promoting the image of medications and that the evidence base for medication has been marketed better.  He implicates the American Psychiatric Association in promoting medications and suggests that the guidelines are biased against psychotherapies.

I am surprised how much discussion this post has received as though the contention of the author is accurate.  Psychotherapy has no image problem as evidenced by one the references he cites about the fact that most patients prefer it.  It wasn't that long ago that the famous psychotherapy journal Consumer Reports surveyed people and concluded that not only were psychotherapy services preferred, they were found as tremendously helpful by the majority of people who used them.  That study was not scientifically rigorous but certainly was effective from a public relations standpoint.

The idea that psychiatry is promoting drugs over psychotherapy seems erroneous to me.  The APA Guidelines certainly suggest psychotherapy as first line treatments and treatments that are part of selecting a therapeutic approach to the patient's problems.   Psychopharmacology is also covered and in many cases there are significant qualifications with the psychopharmacology. Further there are a number of psychiatrists who lecture around the country who are strong advocates for what are primarily psychotherapeutic approaches to significant disorders like borderline personality disorder and obsessive compulsive disorder.  Psychiatrists have also been leaders in the field of psychotherapy of severe psychiatric disorders and have been actively involved in that field for decades.   Even psychopharmacology seminars include decision points for psychotherapy either as an alternate modality to pharmacological approaches or a complementary one.  What is omitted from the arguments against psychiatry is that many payers do not reimburse psychiatrists for doing psychotherapy.

The author's action plan to politically promote the idea that psychotherapy is evidence based and deserves more utilization is doomed to fail because the premises of his argument are inaccurate.  There is no image problem based on psychiatry - if anything the image is enhanced.  There is definitely a lack of knowledge about psychotherapy by primary care physicians and it is likely that is a permanent deficit.  Primary care physicians don't have the time, energy, or inclination to learn about psychotherapy.  In many cases they have therapists in their clinic and just refer any potential mental health problems to those therapists.  In other cases, the health plan that primary care physicians work for has an algorithm that tells them to give the patient a 2 minute depression rating scale and prescribe them an antidepressant or an anxiolytic.

And that is the real problem here.  Psychotherapists just like psychiatrists are completely marginalized by managed care and business tactics.  If you are a managed care company, why worry about insisting that therapists send you detailed treatment plans and notes every 5 visits for a maximum of 20 visits per year when you can just eliminate them and suggest that you are providing high quality services for depression and anxiety by following rating scale scores and having your primary care physicians prescribe antidepressants?.  The primary care physicians don't even have to worry if the diagnosis is accurate anymore.  The PHQ-9 score IS the diagnosis.  Managed care tactics have decimated psychiatric services and psychotherapy for the last 20 years.

It has nothing to do with the image of psychotherapy.  It has to do with big business and their friends in government rolling over professionals and claiming that they know more than those professionals.  If you really want evidence based - they can make up a lot of it.  Like the equation:

rating scale + antidepressants = quality

If I am right about the real cause of the decreased provision of psychotherapy, the best political strategy is to expose managed care and remember that current politicians and at least one federal agency are strong supporters of managed care.

George Dawson, MD, DFAPA

Brandon A. Guadiano.  Psychotherapy's Image Problem.  New York Times September 29, 2013.

What JAMA Psychiatry Doesn't Know About Patient Dumping

JAMA Psychiatry recently posted commentary on a form of patient dumping that I described in a previous post as Greyhound therapy.  The authors' post an impressive chart of state mental health budget cuts and some of the associated problems.  Their solution to the problem "opening a dialogue among providers, funding agencies, and Congress" is a non solution that suggests a lack of appreciation for the details of the problems and how the system of care for people with serious mental illnesses has been systematically dismantled and is no longer capable of providing quality or innovative psychiatric care.  To illustrate my point consider the following 8 points:

1.  The myth of dangerousness is all encompassing.  At some point the government and the managed care industry wanted to make the rationale for admissions to psychiatric units as difficult as possible to ration inpatient psychiatric care.  The standard question is: "Is this person a danger to themselves or anyone else."  This bias has completely disrupted inpatient care.  We now have desperate people who should have been admitted who are lying about suicidal ideation in order to get admitted.  We have people who don't need to be admitted saying they are suicidal and getting admitted.  The point is that this criteria is irrelevant for a whole range of indications for inpatient treatment.  As an example, anyone with a familiy member who has severe mental illness recognizes that there are times when they are completely unable to function due to their illness.  Leaving that person at home to fend for themselves in that condition is not only a bad idea it is inhumane and yet they may not meet somebody's criteria for "dangerousness".

2.  Length of stay in all community based psychiatric units is based on DRG payments.  That means there is a set reimbursement for a diagnosis related stay independent of how long the patient is in the hospital.  As an example a psychosis DRG is one of the commonest DRGs and the last reliable figure I have is that it pays $4,500 per DRG.  That is set by the federal regulatory agency for Medicare reimbursement but practically every managed care and insurance company pays the same way either per admission or per discharge.  If the patient stays 5 days that is nearly the mythical "$1,000/day" that most people believe the hospital is reimbursed.  If the stay is 30 days that is $150/day and less that the cost of most board and care homes.  This is a strong financial incentive for the hospital to discharge the patient as soon as possible.

3.  Despite an emphasis on biological treatments in inpatient settings, there really are no biological treatments that work in the 5 days.  That is the length of stay most hospitals want their patients discharged in.  Most inpatient experts will tell you that severe mental illnesses (as opposed to crisis intervention) often require at least 2 - 4 weeks for stabilization.

4.  Available social service providers have no incentive to assist the hospital with placement irrespective of whether there is adequate housing or not.  The hospital is the least expensive place to house the patient, even if they are stable for discharge.

5.  The economic incentives result in a large patient population that circulates from homelessness to emergency departments to inpatient care.   These same incentives result in the patient being exposed to no single environment that results in their stabilization.  In fact providing thousands of dollars of discharge medications to people who will probably never take them is a massive inefficiency that creates an illusion that inpatient treatment has done something.  My personal conversations and correspondence with many outpatient psychiatrists confirms that most of them consider inpatient care to be a complete waste of time and they acknowledge that they have no good place to send their patients anymore for stabilization.

6.  The same managed care companies that denied hospital claims many years ago currently own the facilities.  They now have case managers essentially running their inpatient treatment and telling the physicians there when a patient must be discharged.  If the doctors working in that environment don't go along they can be forced out or placed in an uncomfortable enough position that they quit.  Managed care companies frequently have proprietary and arbitrary guidelines that dictate when people are discharged.  It is not a coincidence that the suggested lengths of stay are expected to maximize profits and have nothing to do with quality psychiatric care.

7.  Utilization reviewers still exist.  Their job is basically to argue with inpatient physicians and harass them enough so that they discharge the patient.  These physicians were supposed to be "peers" but in my experience talking with them over the years, it was apparent that I was not talking with anyone who had actually worked in an inpatient unit.  Their job was clearly to force me to get the person out of the hospital or play the trump card by denying payment and getting the hospital to force me to get the patient out.  You might ask yourself why they are necessary if their company is paying a fixed fee for inpatient care and I think that is a good question.

8.  The trivial reimbursement for inpatient care deincentivizes access to other assessment and treatment modalities that the patient may need such as specialty consultation, brain imaging, and electroencepaholgraphy.  Patients may be told to come back for outpatient appointments when the treating psychiatrist knows that patient will not return for the necessary appointments and will probably be readmitted soon with the exact same medical problem.

All of these issues combined are why people are discharged to the street or put on a bus.  You can see that the common theme here is actually the rationing of services by the government and managed care industry as well as psychiatry's inability to deliver the quality of care that psychiatrists are trained to provide in this restricted environment.  The suggested solutions in the authors article seem to be written by Joint Commission bureaucrats and will have little impact.

This is a problem that can be solved by psychiatrists but it has to start with a quality approach.  Inpatient specialty training in psychiatry with a focus on providing state of the art assessment and care is necessary.  It is an ideal place to begin to attend to the cognitive dimension of psychotic disorders and mood disorders.  Civil commitment laws need to be reformed with a focus on treatment rather than dangerousness.  There needs to be an appropriate hand-off from the hospital team to  a community team and a housing team.   It is the time to stop demanding "cost effective" treatment from a system that has been practically rationed into non-existence.  It is time to invest in quality to the point that patients with severe mental illness and their families can expect that there will be psychiatric services available as a resource on par with the cardiology services they expect for any middle aged person with chest pain.

George Dawson, MD, DFAPA

1.  Das S, Fromont SC, Prochaska JJ. Bus Therapy: A Problematic Practice in Psychiatry. JAMA Psychiatry. 2013 Sep 25. doi: 10.1001/jamapsychiatry.2013.2824.  [Epub ahead of print] PubMed PMID: 24068366.

A Familiar Story - Another Shooting

The story is familiar and the media writes about it the same way.  A mass shooting and the shooter has anger control problems, social problems, and finally probable symptoms of psychosis.  The "ELF" considerations here were interesting.  ELF is extremely low frequency as specified in this Wiki primer that covers most of the relevant facts.  I grew up about 30 miles away from the original ELF site in Clam Lake, Wisconsin and there were plenty of conspiracy theories and environmental concerns right in the area at the time that surrounded this project including the effect of ELF on the residents.

The usual interviews with politicians about gun access and psychiatrists about whether or not violence can be predicted.  It is a very familiar sequence of events.  The White House is less vocal this time because I think everyone realizes that the government has no interest in solving the problem.  You can click on mass homicide and mass shooting and see my previous posts on the matter for a more complete elaboration.  There seems to be nothing new in the response to this mass shooting other than the question of security at American military installations.

My response is also the same and it is basically the following:

1.  Mass homicide is a public health problem that can be addressed with public health interventions.

2.  Violence and homicide prevention can occur even in the absence of firearm legislation.

3.  Violence and homicide prevention does not require prediction of future events but the capacity to recognize markers of violence and psychiatric disorders and respond to them appropriately.

4.  There need to be accessible speciality programs for the safe assessment and treatment of people with severe mental illnesses and aggressive behavior.  That includes the assessment of threats since they are the precursors to the actual violence.

5.  A standardized legal approach to the problem of the potentially dangerous person and whether or not mental illness is a factor is necessary.

6.  A comprehensive policy that addresses the issues of progressively inadequate mental health funding is necessary to reverse these trends will provide the funding.

All of the above elements require a standardized approach to the care of the aggressive person and there are several clear reasons why that does not happen.  The so-called mental health systems is fragmented and it has been for decades.  It is basically designed to ration rather than provide care.  That is a massive conflict of interest.  Until that is acknowledged by the politicians and advocates nothing will be accomplished.  It is very hard for politicians to acknowledge when they are backing a national agency that essentially endorses rationing and managed care.  You can also compare my writing and suggested solutions to this problem to a recent "call to action" by American Psychiatric Association President Jeffrey A. Lieberman, MD.

How many "calls to action" does the APA need?

George Dawson, MD, DFAPA

Lessons About Clarity and Boundaries from a Sound Engineer

I read Jason Kottke's blog on a regular basis, probably because he posts a lot of stuff that is just interesting from the standpoint of human communication and analysis.  The latest item that caught my eye was this 20 year old letter to the band Nirvana by their prospective sound engineer - Steve Albini.  To set the context for this letter, Nirvana had released one of the the highest selling rock albums of all time two years earlier, so at the time this letter was penned the group was huge.   There is also a documentary out there about the production of that album with commentary from that sound engineer (Butch Vig) and his analysis of the group and the recording that is very interesting.  So the group was huge and they probably had access to the same sound engineer who made the most successful rock album of all time.  I looked at my copy of In Utero and confirmed that the band did in fact hire Albini. The hiring and ultimate product was not without controversy and there are 48 references to Albini in the Wiki piece on In Utero, some of them referring back to the original letter.   I thought it was a remarkable document about providing service, the parameters of that service and the associated philosophy.  I will use a brief excerpt of this letter as an example:

"#2:  I do not consider recording and mixing to be unrelated tasks which can be performed by specialists with no continuous involvement.  99 percent of the sound of a record should be established while the basic take is recorded.  Your experiences are specific to your records; but in my experience, remixing has never solved any problems that actually existed, only imaginary ones.  I do not like remixing other engineer's recordings, and I do not like recording things for someone to remix.  I have never been satisfied with either version of that methodology......"  

This letter does contain the rough language that you would expect to hear from young men before they recognize the value of language that never needs to be censored, but there are potentially important lessons.

I have had the privilege of talking with people in considerable detail about their medical, psychiatric, social and family histories since about 1978.  That is a long time by anybody's standard.  There are some things that jump out of those interviews that seem to not change over time.  I am always surprised by the implicit rather than explicit agreements between physicians and their patients.  That is especially true since managed care companies started dictating the practice parameters of their physician employees on a large scale basis.   I wonder if things might be a lot better if the relationship between a doctor and his/her patient was not spelled out as clearly as the letter from this sound engineer.  I thought I would compose a parallel letter.  It might go something like this .

That is my first attempt to write a letter about what you might expect in seeing me for psychiatric treatment.  I intentionally wrote it in a manner similar to Steve Albini when he described what it might be like to employ him as a sound engineer.  The whole idea of being very clear with people about what they can expect and how they need to interact with psychiatrists in treatment has never been more critical.  For all of my career (so far) I have been an employee of a healthcare organization.  In that situation that adds a dimension to the treatment contract.  For example, do the organization that employs you have the same priorities and the same approach to patient care?  If not, it might be very difficult for you to pen a sample letter like the one I have written.  You can't really talk about psychotherapy or even lengthy evaluations if your organization allows you to see patients in 10-20 minute appointments to refill their medications.

I am very interested in hearing what other psychiatrists would add or subtract to what I have so far.  I would also be interested in hearing about any existing letters.  I think they would also be very useful for psychiatrists starting out of residency or psychiatrists going into private practice after years of working as an employee.

George Dawson, MD, DFAPA

If you send me a letter, with your permission I will scan them into Dropbox and post the links right here with any title that you want me to use including "anonymous":

Violence and Voices

One of my colleagues posted this NYTimes  reference to my Facebook feed this morning.  It is written by anthropologist T.M. Luhrmann.  She has a number of references in Medline relevant to this article.  Her basic thesis is that violent or aggressive auditory hallucinations experienced by people with psychotic disorders are culturally determined.  She concludes with the irony that the cultural factors responsible for a lack of will to initiate any meaningful gun control measures may be responsible for more violent auditory hallucinations than are experienced in other cultures.

What is the evidence?  She sites a cross cultural study of 40 people with schizophrenia in India and the United States.  Across cultures the horrible voice in India were focused on sexual themes and in the US they were focused more on aggression and torture.  There were other directive voices focused on routine directions.  Not a lot of detail.  As a guy who has talked with hundreds of people who were experiencing voices - the common ones are basically background noise like people mumbling or talking at a volume that cannot be understood.  Clearer voices clearly comment on the person experiencing them.  The comments can vary from routine such as what the person is doing to very negative commentary or ridiculing them.  At the extremes voices tell people to harm themselves or others or commit suicide.  Those are the typical voices that psychiatrists are trained to ask about for the purpose of assessing dangerousness, but recent studies show that they are probably poor predictors of actual violent acts in clinical settings.

What about the larger observation that voices would incorporate culturally relevant elements?  It seems to me that would be a given.  As I considered the problem I recalled reading J. Allan Hobson's book The Dreaming Brain when it first came out. He describes acquiring the dream journal of the Engine Man who recorded his dreams in great detail and without interpretation in 1939.  The Engine Man was "fascinated by railway trains" and the content of his dreams that he describes and draws contains a lot of that subject material.  Railway trains were the technology of the day.  They were part of the culture and the conscious states of me interested in technology.  Like the Engine Man it is difficult to conceive of a person experiencing voices or delusions without a cultural context.

It is difficult to imagine scenarios that lead to voices de novo without exposure to a plausible or even science fiction origin.  Hence the common scenario that there is an agency projecting these voices as the most likely cause.  It can also imply motivation for the perceptual changes as well as the content.   I doubt that voices originating as a beam from the police, the CIA, the FBI or Homeland Security occurred before these agencies were invented.

The other association I had is the theory (or axiom) that the prognosis of schizophrenia is much better in the developing world.  This idea came about as the result of a number of World Health Organization Studies and others done in the 1970s to 2000s.  Those studies suggest a better prognosis for schizophrenia in the developing world.  That theory has been called into question based on methodological considerations by Cohen et al.  At the anthropological level, the argument by Dr. Luhrmann reminds me of a similar argument about whether or not primitive peoples were inherently peaceful and became aggressive only after being influenced by social organization.  Large scale warfare only becomes possible as the institutions of civilized society grow.  Primitive man by nature was inherently peaceful and would get involved only in small scale conflicts around issues like marriage and property.  Kealy refers to this as the Myth of the Peaceful Savage.  He dispels that myth in his book War Before Civilization and points out that prehistoric man was as aggressive and violent as modern man.  Violent and aggressive solutions appear to be universal and it is likely that the culture in America is no more violent than what people experience across the world.  The only plausible cultural argument that is rapidly vanishing is the exposure to media violence on a 24/7 basis.  At anthropological level, the basic question seems to be why all human societies seem to regard warfare and aggression as an ultimate solution to unresolved conflict.

The larger issue of course is the fact that the experience of hearing voices is much more than that.  The entire conscious state is affected.  There is not a linear sequence of events that proceeds form a voice to an action.  Practically everyone with that experience has a substantial change in their conscious state.  The usual stream of consciousness is affected as well as mood state and decision making biases.  At times that is detected there can be what appears to be a complete change in the personality of the affected person.  The decisions that they currently make cannot be predicted by your past experience with them.

There are several psychotherapeutic approaches to the problem.  From a psychiatrist's perspective is is generally necessary and advisable to discuss the voices at some level with the patient.  An explanation is necessary that is more than an incomplete biological one as: "You are hearing voices - take this medication and it will get rid of them."  Most people are interested in what it means and culturally and individually based meanings are often useful.  Some of the preliminary cognitive behavioral therapy of hallucinations emphasizes the need to decrease personal meaning and when that occurs the voices may become less intense and disappear.  It should really come as no surprise that talking about voices in certain ways modifies the experience of hearing them or even results in them disappearing.  I would liken it to making a conscious decision to wake up during a dream that you don't want to have and then realizing that the dream is gone.  Although it has not been investigated I would speculate that this ability would be proportional to the degree that a person's usual conscious state has been affected.


George Dawson, MD, DFAPA

Hobson JA.  The Dreaming Brain.  Basic Books, Inc.  New York, 1988.

TM Luhrmann.  The Violence in Our Heads.  New York Times September 19, 2013.

Cohen A, Patel V, Thara R, Gureje O. Questioning an axiom: better prognosis for schizophrenia in the developing world? Schizophr Bull. 2008 Mar;34(2):229-44. Epub 2007 Sep 28. Review. PubMed PMID: 17905787; PubMed Central PMCID: PMC2632419.

Kleinman A. Commentary on Alex Cohen et al: "Questioning an axiom: better prognosis for schizophrenia in the developing world". Schizophr Bull. 2008 Mar;34(2):249-50. Epub 2007 Dec 3. PubMed PMID: 18056682; PubMed Central PMCID: PMC2632393.

Keeley LH.  War Before Civilization - The Myth of the Peaceful Savage.  Oxford University Press, 1996.

American Psychosis - The Final Take

I finished reading E. Fuller Torrey's recently released book American Psychosis - How the Federal Government Destroyed the Mental Illness Treatment System .  I recommended it on the basis of a a quick initial read of a brief section on managed care but can provide additional details at this time.  I will start with the conclusion.  Criticizing an expensive, fragmented, and poorly conceived system of care for severe mental illness is a fairly easy task for any psychiatrist who tries to provide care for the target population of people with schizophrenia, bipolar disorder and severe mood disorders. This book concentrates many of the references about deinstitutionalization, incarceration of the mentally ill, victimization of the mentally ill, and aggression and violence by the mentally ill in one place.  In the conclusion Dr. Torrey also recommends some 10 potential solutions to the problems and more importantly suggests the some of these need to be implemented on a small scale rather system wide.  

I am sure that Dr. Torrey and the publisher of this book would not be very happy if I put all 10 of his proposed solutions on this blog, so I am going to focus on one that is consistent with my initial post and one of the major themes of this blog:

"For profit funding of of public mental illness services has been tried and it does not work." 

This is the real experience of anyone who has worked in psychiatric acute care and by that I mean the hospital in your community where people are brought in by the police on emergency holds.  Even in that setting there are levels of acuity.  In a metropolitan area there may be 8 or 10 psychiatric inpatient units but only one or two of them will accept patients with high levels of aggression or suicidal behavior.  In an ideal world these would be units where there are staff with high levels of expertise in treating these severe conditions, but the reality is that economic considerations are at the top of the list.  There needs to be adequate staffing for close supervision and the staff have to be able to deal with high levels of aggression toward self or others.  There also needs to be expertise in recognizing and treating alcohol and drug intoxication and withdrawal states.  There is usually minimal attention paid to the therapeutic aspects of the environment.

When I first started working in that environment it was the late 1980s.  I had just completed a three year stint as the medical director of a very good community mental health clinic that offered case management and Assertive Community Treatment.  I was well trained in community psychiatry at the University of Wisconsin Psychiatry Department and it was good to actually practice it with a team of highly motivated people.  
                                                                   
The first months on the inpatient unit resulted in several "denials" by insurance company intermediaries functioning to ration care.  Keep in mind that all of these patients were in the highest acuity unit in the hospital, had problems with suicidal and aggressive behavior, and many needed detoxification. The rationale of the "peer reviewers" was the the patient did not require acute care or the care could be provided at a less intensive facility.  Apart from county detox facilities that had policies against admitting suicidal or aggressive patients - no less intensive facilities existed.

When you are in that environment trying to provide care, it is pretty obvious that this peer review process is basically an insurance company game to make money.  In the small print in the denial letters there was an option to appeal all denials to an administrative law judge within the state.  I asked my colleagues and nobody had tried that route.  I collected 12 denials and requested a hearing in front of the administrative law judge.  I took a day of vacation to go to court.  A week before the hearing I was informed that my hearing was cancelled and the administrative law judge decided in favor of the insurance company.  I appealed to the Attorney General on the basis of conflict of interest stating that the peer reviewers worked for a competing organization and therefore this was anticompetitive activity.  The AG informed me that they were independent contractors.  How can you be an independent contractor if you collect a paycheck from the organization that is denying care by your competitor?  It was clear to me that the state government was very friendly to the managed care industry.

The whole managed care strategy for rationing care or in  extreme cases shutting down entire psychiatric units was outlined in my previous post on overutilization.  It is the basic money making strategy of managed care organizations.  It essentially doubles down on rationing.  That occurs because hospitals are paid a set amount for taking care of people regardless of how long they are there and that amount is denied in as many as 10% of cases.  If there is one deficiency of this book it is a lack of granularity on this issue.  Dr. Torrey approaches the problem as a top down problem of policy deficiency, driven by an ideology that bed capacity could be shut down and not missed either because of the toxicity of state hospital settings or too much faith in the federal initiated community mental health movement. 

Assuming that a patient can actually get the level of acute care that they need without being thrown out of the hospital by an insurance company, the fragmentation of care does not stop there.  Even though insurance companies say they are emphasizing outpatient care, getting an appointment may be impossible.  The prescribed medications may be denied.  Housing options or community case management for people with severe mental illness are not usually available unless the insurance changes to a public option.

American Psychosis covers the funding and policy issues on a global level before it gets to the suggested solutions.  Excellent examples are given to illustrate these points.  For example, North Carolina is given as the example of what happens when a state mental health system is privatized (p 158).  The parameters of the dramatic deterioration in services that resulted from this maneuver is a well documented example of what happens when a for-profit entity begins to manage care and shift the responsibility for care of serious mental illnesses to the correctional system.

American Psychosis is a well organized analysis of the problems that occurred as the result of an initiative in the Kennedy administration.  It contains a lot of information and references about what has happened as the result of these decisions.  There is also a subtext and that is it is written from the perspective of a psychiatrist who has been a thought leader on the issue of treating people with severe mental illness.  Only a minority of people in the United States understand that perspective and I think that there will be predictable backlash from the constituencies that believe a severe mental illness is a preferred state and that everyone should have the right to enjoy it.  

That is not the experience of any acute care psychiatrist and Dr. Torrey presents that perspective very well. 

George Dawson, MD, DFAPA