Tuesday, July 31, 2012

Diane Rehm Show: Mental Health Under the Affordable Care Act

I was a guest on today's Diane Rehm Show on National Public Radio, along with Rachel Garfield from the Kaiser Family Foundation, Pamela Hyde from SAMHSA, and Richard Frank, the Harvard health economist.

The topic was about the Accountable Care Act (ACA) and its potential impact on mental health and addiction services.

They already have the recording up, as well as a transcript.


Sarebear said...

I read all your parts, Roy (sometimes the question involved too) and liked it.

rob lindeman said...

This exchange disappointed me:

And we now know that the Colorado shooting suspect, James Holmes, who's now actually been charged, was under psychiatric treatment for we don't know exactly what. But the question is, when does a psychiatric professional feel the obligation to report that kind of illness to some higher authority?

So I -- from state to state, there are different laws about what the level, you know, at what point you cross that line and break a patient's confidentiality because of public safety.

What Roy said was perfectly sound and sober. I only wish he had taken the opportunity to point out to Rehm and her listeners that we haven't the foggiest idea as to Holmes' mental state. I believe we're not yet 100% certain Holmes was a client of Lynne Fenton.

Sideways Shrink said...

Okay, now, there are many reasons I use the moniker "SidewaysShrink", but in this case of clueless it was interesting. I had already heard the Diane Rehm episode in question and have been following the Shrink Rap for and still had to do some Googling to figure out which one was Roy. I had thought you guys were all located in Maryland/Baltimore area, but still maybe thought it was that public health shrink from Harvard who was Roy--because no one one the episode was named Roy.... I am simple but I prefer to go by the name Sideways like Stephen prefers to go by the name Roy.... Well, okay, not at all the same as Roy did a fantastic job because Diane Rehm is real journalism--turn on a dime--known your stuff. I first discovered her almost 20 years ago when I was at Hopkins for my first PhD not to be and I thought she was just a radio show local to the area.(HA!) It must have been exciting to be on her show!

Sideways Shrink said...

I have a question for you Roy about the ACA that was touched on in the Diane Rehm show but did not get fully addressed. It has to do with increased Medicaid reimbursement under the ACA to Medicare rates. I think that it would be one of our finer moments in America if we insured 36 million more people under the Medicaid program at higher rates for providers and all of these newly insured people found all the providers they needed. And while Diane asked how we could ALL, as a society, afford to treat the newly insured mentally ill, as someone 10 years out of school with a student loan balance of around 90K+, I wonder how psychiatric providers, already underpaid due to private insurance practices like 3rd party carve outs, managed care and limited patient access due to limited provider networks(due to low reimbursing networks usually).
I am stating that I cannot afford to see a panel of patients at Medicare rates all week long--doing mostly psychotherapy and medication management and seeing maybe 10% of patients once a month for an hour long session. I feel VERY conflicted about this fact. Given the increased psychiatric and medical complexity of these patients and that I have no front or back office staff to help coordinate the care and I would quickly be lost, burned out and broke. What the ACA did not build in was any loan repayment programs to motivate younger providers to take on sizable panels of Medicaid or Medicare patients.
I started out with $250K student loans. (Sure, the advanced training and that 2nd child are what compounded the private loans to such a high level--but you should see my youngest daughter: she has a huge heart, she sings, she has a high spatial IQ, loves Curious George--well worth 50K?....) I doubt any of you shrink rappers had that high of a balance to start, but if any of you, especially Roy (teaching new students some of whom will end up with those kind of balances)want to comment on the differential between student loans and reimbursement in psychiatry, I would appreciate it.

Dinah said...

Sideways: You can find us here:
(it's the media link on our sidebar)
names, pics, whatever.
And friend us on Facebook at Shrink Rap Book (also in our sidebar)
if you like photos, ducks, updates, etc

Lemelous said...

Years ago, it was clear to me that Roy was Steven Roy Daviss. Dinah helpfully had something posted on the blog thanking Steven R. Daviss for his technical assistance. That was too much of a coincidence. She eventually removed it. Maybe Roy was not yet ready to come out from behind the curtain. Of course, had he truly wanted to preserve his anonymity at that time, he would not have chosen his middle name.

Sarebear said...

While I think Rob has a valid wish, since everything being discussed was prompted by this shooting, this suspect (well the law calls him a suspect, but he let himself get caught, among many other things), on the other hand this specific comment and question says that they don't know exactly for what he was under treatment (acknowledging as Rob says, that we don't know FOR SURE that he was under treatment, but follow me a second here), and the question while it could be interpreted to be about Holmes, I feel has more of a different intent (even if not worded the best for the intent I feel it may have).

That intent would be this: For other ill patients who may possibly become violent/harmful, when does a shrink feel the obligation to report that?

As much of the media is doing, however, the question was worded "that kind of illness" which is quite overgeneralizing, that there is a "kind of illness" that tends to be violent.

From what the shrinks on this blog have said about statistics, the mentally ill are more likely to be victims of (violent?) crime than (violent?) offenders. No one illness is a label that, Hey, they're likely to be violent . . . at least as far as I understand it.

So that particular phrasing I object to, but I think Roy saw past that to the intent, the part that many people want to know the answer to, who aren't familiar with the issues of "duty to warn" and whatnot that shrinks have (like child abuse, impending harm, reporting colleagues for sexual misconduct with patients as I think they've said Maryland requires, etc.)

Now, would it have been nice to pick up on the overgeneralizing of the "that kind of illness" and comment on it? sure. I know here and elsewhere they have, and they've responded to that issue (and I can't remember, but they may have responded to that issue elsewhere in this broadcast.)

Anyway. Rob points out something I actually agree with, while I feel the intent of the comment/question was to basically find out stuff about reporting issues, and perhaps threshholds of reporting (which can often get tricky, I would think, where exactly is the line? some may be clear, some not so clear.)

Sorry for rambling!

Anonymous said...

I think one of Rehm's questions illustrates how much stigma still exists, particularly with the media.

She states, "So that if I'm taking a certain kind of drug, for example, and I say, I'd rather that that information not be released, but suppose it's a drug to treat me for some really serious mental illness, does my right to privacy override the public's need to know about me?"

Really? Was she serious? Does the public have a right to know what medication she takes?

Sammi said...

Dear Anon,
Of course not. Do you know what your doctor and/or shrink takes?
You must be aware that due to off label prescribing, a lot of people take anti-psychotics for insomnia. A lot of women take anti-depressants for menopausal and Peri-menopausal symptoms.Are these pych issues? Doubt it. How many men are taking testosterone supplements, without an accompanying psych dx? Good old US of A.
Not a robot but I wish I were.

Anonymous said...

Sammi, I guess I'm perplexed that she would even ask a question like that. I don't owe the public crap when it comes to what medications I take for get this...gasp...a serious mental illness. Questions like hers only reinforce the reason many of us choose to stay silent about our diagnoses. I don't know why I'm surprised by her question, though, because the media thrive on fear mongering and sensationalism.

When I heard about Holmes, I told my sister, "Just wait, the media will be frothing at the mouth to discuss taking away more rights for those diagnosed with a mental illness. They love this stuff." I wish I had been proven wrong.

If she really wonders if the public has a right to know what meds people who are diagnosed with serious mental illness take, then she is telling the public exactly what she thinks of all of us.

I have news for her. I'm not Loughner. I'm not Holmes. I'm sorry that they did those horrendous things, but it has not one single thing to do with me. What medications I take is none of the public's darn business.

Anonymous said...

Sammi, I hope it didn't seem like my rant was directed at you, it certainly is not. I'm just sick of the media talking about "the seriously mentally ill" like we all need to be locked away.

I appreciated the response that gave the facts about violence, but I think that message gets lost. When people think of serious mental illness, thanks in large part to the media the first thought is often about violence. That's sad.

Sammi said...

Dear anon,

I am glad your rant was not directed at me because I was directly answering your question which was "does the public have a right to know what medication she takes?" I started off with "of course not". My toehr comments were meant to that up. The public has no right to know who takes what for what. Some jobs may require disclosure of certain conditions and treatments. disability and Life insurance companies will want to know, and it is important to be honest or they can and will deny a claim. There are a few other examples but the PUBLIC never has a right to know.