Sunday, April 06, 2014

Dear Congressman Murphy: Regarding HR 3717

American Enterprise Institute, AEI, a conservative think tank, held a panel on Fixing The Mental Health System, What Congress Can Do.  I posted the discussion above, the talking begins at 12 minutes.  The panel is introduced by Dr. Sally Satel, and the speakers include:

  • Congressman/Psychologist Tim Murphy who talks about legislation in Congress, HR 3717.  This bill pushes the federal government to provide more services -- a good thing -- and it also ties in requirements for Involuntary Outpatient Treatment (also known as Assisted Outpatient Treatment or AOT).  The New York Times has discussed this in Mental Health Groups Split on Bill To Overhaul Care.  
  • Dr. Jeffrey Lieberman, the President of the American Psychiatric Society
  • Dr. E. Fuller Torrey of the Treatment Advocacy Center
  • Former Congressman Patrick J. Kennedy
If you'd like to watch the event, the video is above, if you want to read about it, read Here. 

I don't want to dwell on the issue of involuntary treatments today, but instead, I'd like to make some comments on H.R. 3717 The Helping Families in Mental Health Crisis Act.  I've read about the bill, I have not read the full text, but if you'd like to, it's here. 

Dear Congressman Murphy,

I'm no fan of HIPAA, as a physician, I find it makes it more difficult to get information from other clinicians.  Your point, however, that HIPAA prevents a doctor from getting information from a family is not quite right and you were more on target when you said it was misunderstood.  Physicians can listen, and families can talk, but privacy laws mean that physicians can't release information without the patient's permission.  Actually HIPAA defines all sorts of entities that can get medical information, but there is nothing in it that says a family member can't tell a physician about their concerns or relay past history.  Sometimes, clinicians refuse to release information to families or even other physicians, citing HIPAA, when in fact, they haven't specifically asked the patient for permission.  Sometimes doctors or facilities are lazy, sometimes they are misinformed, and sometimes they are afraid of being sanctioned or sued so they err on the side of being overly careful about whom they communicate with.  For the most part, I don't believe that doctors should release psychiatric information unless a patient consents to this.  Lets hope that everyone's judgement on these issues gets a lot better. 

In talking about access to care and a shortage of psychiatrists, because psychiatrists are in such demand, many psychiatrists have chosen to opt out of participating with health insurance.  I've written about that Here.  Part of the access problem lies with the fact that insurance companies either restrict patients to seeing in-network psychiatrists, or reimburse less if patients go out of network.  At the same time, insurance companies will list psychiatrists as being in their network when they are not, creating the false impression that the network has plenty of providers: see this Wall Street Journal Article.   So what about increasing the number of available psychiatrists by requiring insurance companies to reimburse the same for both in-network and out-of-network treatment when access to care becomes difficult?  If a family is told that the next in-network appointment is 6 weeks away, but an out-of-network doctor can see them the next day, should the insurance company really be permitted to save money and reimburse less?  And should insurance companies be permitted to have "Usual and Customary" rates that are far below the community standard?  And perhaps if Medicaid and Medicare would reimburse for out-of-network services (they don't), the number of treatment options might open up. 

Finally, you talked a lot about the standard of "imminent danger" as being too high standard for hospitalization.  That's all well and good, and I agree with you that we shouldn't be waiting for metastatic disease (as your comparison mentioned) to begin care, on an inpatient unit if needed.  But it's not just about that standard of care for forcing treatment, it's about what insurance will reimburse for.  Have you ever tried to admit a patient to a hospital?  Insurance companies generally will not authorize treatment for psychosis alone.  The only level of illness that they will authorize inpatient care for is the same level that one needs for involuntary commitment: imminent dangerousness.  So you can drop the level of illness it takes to get a patient admitted -- and I presume you mean by allowing for involuntary treatment -- but does it matter if the law changes to a "need for treatment" standard if insurance companies don't agree that the patient needs treatment?  I asked a woman the other day why she didn't sign herself in voluntarily after a serious suicide attempt -- she was being transferred from an ICU and was distraught that she was being 5150'd (California lingo).  She told me the doctor said the insurance company wouldn't pay for the admission if she wasn't committed, otherwise she would have signed herself in.    One ER psychiatrist I know was asked by the insurance company if the patient's gun was loaded.  Does that matter?    If the Navy Yard shooter had been brought to the hospital by the police, as he should have been, they may well have let him go if it was believed that insurance wouldn't pay for an inpatient stay.  And while severely mentally ill people may have higher rates of violence, studies have shown that treatment deceases violence.  In fact, patients who are seen weekly after a hospitalization are half as likely to be violent as the general population -- voluntary treatment makes a big difference.  But getting that level of care for our patients in the public mental health system only happens with the few who get put with Assertive Community Treatment teams. 

One thing is clear, before we start forcing care, let's make sure there is even care to be had, and that those who want it, or can be encouraged to get it, have a means to do so. 


Anonymous said...

Very good comment.
Money comes first quality of care and patient come last there should be a balance.

Anonymous said...

Not relevant to this post, but I can't find a contact page. I just wanted to ask about patient complaints and what the ideal protocol should be. My long standing GP dismissed my want to see a pscyhologist, and I have found a different GP to accommodate me for that request but I have considered complaining to him, not to point fingers, just so he doesn't dismiss people with the same issues as myself. I would love to hear your perspective(s)

Simple Citizen said...

While working on an inpatient psych unit, I can't even count the number of times I have heard a doctor or nurse on the phone say:

"I can't confirm that person is here nor tell you anything about a patient's case or care - but I will gladly sit and listen to anything you would like to tell me about your family member, their history, and what might be helpful for them."

HIPAA doesn't get in the way of getting information from family members, it just makes for strange conversations.

Anonymous said...

The thing that makes me sad is that HR 3717 creates more of an adversarial relationship between psychiatrist and patient. If I have to worry as a 40 year old woman, that my psychiatrist is going to be tattling to my parents, I'm through talking to my psychiatrist. I am an adult, and I expect to be treated that way.

Further, this legislation will only make the antipsychiatry groups stronger, because it will result in more angry patients leaving the system. I hate for that to happen, but it will happen.

If mental health professionals want patients to talk to them, then there has to be trust. You can force things on patients, but what you cannot make them do is talk to you. If they do not trust you and feel safe with you, then many will stop telling you things. I would be through talking, and I know others would be to. This isn't the way.


CatLover said...

If I were inpatient, I wouldn't want my psychiatrist talking to my family either, other than my spouse. But my experience was when I asked the psychiatrist to call my husband, some would not, nor would they call my therapist or regular psychiatrist. What's up with that? In response, I stuck it in my advance directive that they are required to get permission from my spouse to make treatment decisions, but I haven't been inpatient since, so who knows if that would work.

I'm with Pseudo-Kirsten. I have known too many people whose families circle the wagons against them and get away with it because they are doing it against the only one in the family who went in for treatment and got labeled. Therefore, they can call that person the crazy one. It works well for awhile, until care providers figure it out. In a hospital environment, the patient wouldn't have a chance because nobody knows them.

Anonymous said...

excellent points made.

when i was released from the STATE psych hospital, they gave me a one month prescription or so for my medication. but it took four months to get into the psychiatrist at the community mental health center.... it was actually to my benefit, as withdrawal went pretty well, and i ended up cancelling that appointment and never getting back on psychiatric drugs. but i agree that forcing people to get help isn't the answer, particularly since many who want help aren't able to access it is crazy. -- liz

a psychiatrist who learned from veterans said...

Having a patient committed for treatment pretty well abnegates an insurance reviewers being able to say it's not a medical necessity as part or your discussion suggests. As far as HIPAA is concerned, I generally agree that you can listen, but to some extent that is a disclosure itself because it's unlikely you would be listening if the person weren't your patient.

Anonymous said...

Another good link which includes a couple of people testifying who oppose the ACT.

Congressman Murphy is quite rude to those who disagree with him. It's silly to think someone has to have read the entire bill to form an opinion about it, they just have to have read enough to know there is some part of it they do not support. I have read enough of it to know I don't support it. I hope the way he talked to those who oppose his bill is not the way he speaks to patients under his care who disagree with him, or no wonder he has to result to force. I can't imagine they would want to work with him.


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