Thursday, February 01, 2018

Insurers, Not Legislators, are the Gatekeepers to Care, and a Call to Deep Six the Term "Worried Well."

Pete is on the Interdepartmental Serious Mental Illness Coordinating Committee,  a group operating under the Department of Health and Human Services. He is an extraordinary writer and a tremendous mental health advocate.  His post inspired me to rant at him (Me rant?  Shocking, I know...) and Pete and I are both posting my response.  I can't begin to capture the essence of his post on the controversy over the NREPP website, nor will you need to understand that to read my response, but  please read about it at the link above.  
Dear Pete:

Thank you for your latest blog post on the work Dr. McCance-Katz is doing and thank you, again, for serving on the ISMICC.  Let me start by saying that after 25+ years as a psychiatrist, I've never heard of the NREPP website, so I'm not certain whether it's it is a good thing or a bad thing that the website is now down.  Instead, I'd like to respond to some of the things that were said in the course of your blog post.

You used the term "worried well."  Please don't use that term, ever.  It implies that there are people with legitimate suffering because they have "real" mental illnesses, and those whose suffering is trivial because they don't have "serious" mental illness.  Suffering is suffering-- it all hurts, and sometimes those with no obvious signs of mental illness surprise us all when something suddenly goes horribly wrong. Psychiatric care is expensive, poorly reimbursed, time consuming, and stigmatized; people don't present for treatment for trivial reasons. There is the implication that some people are more deserving of care in a way we would never dream of bifurcating in any other field.  Could you imagine if you went to the ER with chest pain and were derided because it turned out you had heartburn or a pulled muscle and were not having a heart attack?  As doctors, we help people who are in distress, we don't make the distinction about whose suffering is valid and worthy of treatment. 

I am all in favor of giving more resources to people with chronic and disabling mental illnesses -- these are society's most disenfranchised members, their suffering and the suffering of their families is immense, and they use our resources one way or another.  If not through appointments with psychiatrists and the cost of their medications, then through lost productivity, the cost for medical care incurred from unhealthy life styles, and the cost of institutionalization.  What I find difficult about these discussions is that psychiatry is the only arena where advocates ask for money for one set of patients at the expense of another.  We don't ever suggest that money to treat metastatic lung cancer should come from denying treatment to those with basal cell carcinomas.

While I have you here, I'd like to bring up a related topic that perhaps you can get the ISMICC committee to look at, one that all of us might be able to agree on.  When the topic turns to serious mental illness, the loudest and most controversial agenda is about legislation to make it easier to involuntarily hospitalize patients.  While there are cases where this is an issue, for those of us in practice, there is a bigger issue: the real gatekeeper to getting very sick people adequate and optimal care is not the law, the gate keeper is the insurance/mangled care industry.  Insurers have a erected a barrier to inpatient treatment which has set the standard for admission as "imminent danger."  There are times when everyone can agree that a patient needs to be in the hospital: the patient, the family, the doctor, but if that patient does not present as being dangerous, it has become nearly impossible to get him or her into a hospital bed.  This has trickled into our standard of care: psychiatrists no longer try to hospitalize patients who are not dangerous (usually suicidal) because they believe an insurance company will not authorize the the admission, that an ER will release the patient.

So the few available beds fill with admissions from the ER of people who are so depressed or so psychotic as to be dangerous, and elective admissions just don't end up happening. What does happen is that the few available inpatient beds get taken by very ill, very dangerous patients  and the acuity level on inpatient units is very high.  They often require security officers, and the environment is anything but healing; in fact, inpatient units have a high rate of assaults for both the patients and the staff.  And then we wonder why people won't voluntarily admit themselves to these units when they are sick.  This is the point where people in favor of easier standards to involuntarily admit patients shut me down: they say the patients have anosognosia, they don't know they are sick and they won't get care no matter what, and issues of safe, healing environments or medications that don't cause awful side effects are irrelevant.  I beg to differ with that argument, and still contend that if psychiatric care was kinder, better funded, more palatable, and not stigmatized, then more of those who are not aware they are ill could be swayed to get care.  

Psychiatry is the only medical specialty where the standard for admission has become life-threatening illness, not just being really sick. 

It would be so helpful to all of us if there were more beds available and if insurance companies were not allowed to deny admission to very sick people because there was not an imminent threat of death.  I do believe that is something that everyone in all the tents can agree on, and it's a good starting gate for all of us.  



Joel Hassman, MD said...

"So the few available beds fill with admissions from the ER of people who are so depressed or so psychotic as to be dangerous, and elective admissions just don't end up happening. What does happen is that the few available inpatient beds get taken by very ill, very dangerous patients and the acuity level on inpatient units is very high. They often require security officers, and the environment is anything but healing; in fact, inpatient units have a high rate of assaults for both the patients and the staff. And then we wonder why people won't voluntarily admit themselves to these units when they are sick"

Thank you for writing this. It is exactly what is destroying acute care. Addicts and prisoners are not in need of psychiatric care services unless they have active definable mental health care symptoms causing disruption and dysfunction in quantifiable ways.

It is time for psychiatrists as a sizeable majority to advocate for the needs of mental health care interventions, not the alleged needs of the courts. Providers need to grow a new set of gonads and do what is right and responsible, not what is easy and convenient, or worse, letting oneselves be intimidated by clueless, reckless judges!!!

Oh, and these same judges never seem to allow these violent cretins who assault patients and staff be charged and judged for these acts. What the hell does that say about the forensic agenda these days, eh, colleagues!?!?

Deeds, not words are what define us. Maybe the correctional system can come up with a few extra bucks and pay psychiatrists $200 or more an hour and that would entice those who think with their wallets to work for the prisons with more interest?

Notice I don't even offer in one sentence working in corrections for any altruistic, caring interest. Every psychiatrist I have met who has done correctional work seems to talk money and convenience as their primary goals to be there. I am sure someone will correct me, but, doubt several will.

Joel Hassman, MD

Steven Reidbord MD said...

I respectfully disagree with your "worried well" point. First, in the Pete Earley post you linked, the phrase was in quotes. It was a straw-man argument and a term he doesn't necessary use himself.

More important, there's a useful distinction between functioning outpatients and the seriously mentally ill (SMI). This doesn't mean the former should be ignored or shortchanged, of course. And they are not, technically speaking, "well." But to claim everyone's problem is equivalent — that everyone is "equally deserving of care" — is nonsense. Your ER example actually makes the point: present with chest pain and you get top priority. It may eventually turn out to be heartburn, but it was the presentation that mattered, not the ultimate diagnosis. Show up with flu symptoms instead and you may wait hours.

It OUGHT to be the same in psychiatry: psychosis and similar severe conditions should get top priority — even if the diagnosis ends up being substance abuse, or even histrionics — while the miserable-but-functioning can wait like the flu-sufferer. Yes, such people may be a suicide risk... and as soon as that's known, they go to the front of the line. In contrast, existing psychiatric services are based on economic, not medical, triage. That's why they don't work as well as a medical ER.

Sure, I wish the anxious and depressed who come to my office were able to find and afford services more easily. But I'd like this even more for the psychotic street people who aren't suitable for my office. Let's not engage in false equivalence.

I do agree with your point about dangerousness as the standard for psychiatric admission. We seem to have forgotten that inpatient treatment is still treatment, not incarceration.

R. said...

While I get the point that Steven is making when he says, "there's a useful distinction between functioning outpatients and the seriously mentally ill," the problem is that these categories are not static. Most people who are seriously impaired by mental illness had a point where they were experiencing symptoms but still functioning. And many of those functioning outpatient could easily become seriously impaired without treatment. As it is now, we basically wait until people's lives have already fallen apart and they are in imminent danger before we acknowledge the seriousness of their illnesses. While the suidical individual does obviously need immediate attention, often these individuals have been seeking out help for months and trying to communicate that they need help in order to stay afloat but get blown off because they are still "miserable-but-functioning."

Anonymous said...

For real? We can get rid of the term worried well when psychiatrists are willing to work with patients with more severe depression and not just a tad anxiety or a bit of sadness. There is a difference and you're naive and privileged to suggest otherwise. Those of us who can't get quality care know it. We wish to god we were just the worried well. Get off your high horse and tell your colleagues we deserve treatment as well.

Joel Hassman MD said...

Really, inpatient treatment is still treatment, not incarceration? Tell that to the few true psychiatric patients who are in state inpatient units these days, at least in Maryland. No, sorry to inform readers here along with Dr Reidbord, judges have made psych units defacto correctional facilities, just forgot to tell the people who haven't committed crimes who were admitted to these state facilities there are prisoners there along with them.

But, hey, with the way the dialogue is going after the latest shooting incident in Florida earlier this week, politicians and judges will be even more creative in criminalizing mental health, and, many colleagues will do what comes naturally. Gee, isn't that silence deafening to some here???

Ah, history, what a b---- to those who don't want to acknowledge it. How many more times to we have to watch psychiatry and mental health in general be weaponized by cultures who just lose control of the citizenry....

Dinah said...

Steve, I never meant to imply that all illnesses and types of suffering are equal, I just find that this whole concept of 'worried well,' vs serious mental illness is an odd divisor in a way that no other field has. When someone is in pain, they are in pain, and some people do suicide without telling anyone. And it is exactly what R said that I see in practice: while there are chronically and persistently people with psychotic disorders living on the streets, many people have episodes, and between episodes they are well and function. This is not the differentiation that the "serious mental ill folks" want to make: the division is a diagnosis-based divider. Case in point, the committee's patient representative is Elyn Saks. Dr. Saks has schizophrenia, she takes medications for it, hasn't been hospitalized since the 1980's, is happily married, has a masters from ?Cambridge, a law degree from Yale, is qualified as a psychoanalyst, wrote a best seller, runs a law institute and has received a MacArthur genius grant. She functions just fine (oh, I should function as such...), but the schizophrenia diagnosis means she is seriously mentally ill.

As far as the Chest pain triage vs flu issue goes, well, someone made that call, but many of the people pushed to the front of the line will have heartburn, and tens of thousands of people with the flu will die. I don't have an answer here.

I really do think we need better access to services for everyone. I just don't see how it helps to divide people with suffering. And fyi, my patients with serious mental illnesses talk about the exact same things in psychotherapy that my patients who carry diagnoses without that designation.

Psychmd said...

Paitients should be able to choose the treatment they want, And pay for it.

Insurance companies aren’t paying with their moneiy, they are paying with the patient’s money. Insurance is a parasite.

Insurance is based on risk sharing. Public assistence is not insurance.

The cost of insurance should be the average cost of care for that population, with enforced co-paynents to limit frivolous requests, and loans for co-payments to ensure access when needed.

Insurance is like a shock absorber, it spreads shock over a larger system, dampening it.

Insurance systems should be modeled after car suspensions.

If you know of a good hospital for a deep pocket patient, tell me. I can’t find it. Cedars Psychiatry closed, rather than be prostituted. Academic centers try to find a financially viable compromise, but can’t.


Steven Reidbord MD said...

Sorry, I don't swing by here as often as I used to.

@R, @Dinah: I agree these categories ("functioning outpatient" and SMI) are not static and cannot strictly hinge on diagnosis. Yes, there are articulate, employed, apparently stable folks who suicide, and others with schizophrenia who are high-functioning. But they are the exceptions. The vast majority of anxious and depressed folks can wait 2 weeks for an appointment, while an actively psychotic person will be in jail, ruining his life, or sleeping in a gutter if not seen in the next day or two.

Dinah, you wrote, "I really do think we need better access to services for everyone. I just don't see how it helps to divide people with suffering." The reason I raise any of this is because I favor a single-payer, taxpayer-funded system of health care coverage in the US. Such a system cannot cover everything. When I think about what should be covered, I can't justify the weekly psychotherapy for the very successful but miserable lawyer in my practice deciding whether to divorce. I can justify regular check-ins with my patient with schizophrenia on clozapine, even though he's doing remarkably well (although not like Elyn Saks). A 2-tier system of care seems inevitable, in psych and in medicine generally. Admittedly, the line between serious and less-serious is fuzzy in our field. But there's got to be a line there somewhere.

@Anon raises the good point that many (most?) office psychiatrists avoid the severely depressed, and other "risky" or "difficult" patients. I think it's legitimate to prefer working with some conditions more than others — some neurologists specialize in stroke, others in epilepsy for instance. But systematically excluding hard cases seems to be unique to outpatient psychiatry. We ought to look at this as a profession — and in the meantime, at the very least advocate for the agencies that do treat such patients.

Dinah said...

Historically, CMHCs have taken the difficult patients/all comers. They are better equipped than private practitioners to handle high-needs patients because there is a team, including case managers who will ferry patients to appointments and coordinate care, and there is coordination between programs, such as occupational rehab or day programs, and there is a mechanism in place to get people to higher levels of care. These are not things that psychiatrists are good at. (20 years of experience working in CMHCs). Absolutely we should support them!

How do we divide who gets what care? Miserable lawyer shouldn't be using our resources for weekly therapy, but quarterly med checks with clozapine schizophrenia patient are okay? Where is the precise line on what services should or shouldn't be reimbursed? Many of my patients in private practice fit the criteria for serious mental illness....perhaps they've been hospitalized in the past for serious depression or bipolar disorder or had ECT or are well now by virtue of the 5 medications they are on plus psychotherapy. But news flash: these talk about the exact same things in therapy that those without 'serious' mental illness talk about. Usually interpersonal relationship issues.

We don't limit how many times you can go to a doctor with a headache or complaint that your stomach hurts, even if you've had a negative work up.

I don't have the answers. I just don't think anyone else does either.

Anonymous said...

Good Evening,

Psychiatry must recognise banking and its life-blood. Usury finance. Coming from a family of doctors inc specialists of mental health I remind colleagues to go back to their bible.


His closest student Otto who accompanied him for 16 years (who knows Freud better?) described him simply as “ A very paranoid man.”

Psychiatry , in cut and pasting his theory’s along with the modern psychiatry’s main method - World War 1 beds, with techniques in evolution from “shell shock” you have the blue print used now, along with all its errors.

As commmited Doctors you have to go to the root of the problem. We live in a world run by an impossible mathematical certainty. 2% interest must give back a 4% return and so on.

You have to be clinical in following the money. Common sense tells us that the world is finite but it’s financial model is insane. It’s pure insanity. When the model collapses. A mathematical certainty - this is the hidden psychosis.

Peoples modern 9-5s, depression, illnesses, debt, anxiety all to compete in the world and just live leads to these breakdowns first societal and then individual.

As money becomes devalued then more patients will see fewer doctors, as is happening over in the UK with the 10minute rule. This is called austerity. Is their any co incidence psychiatric disorders have mushroomed since 2008 and the financial crisis?

In ancient philosophy societal disorder was inseparable from personal disorders, it is the failure to join both that places all of us on the Titanic.

The key thing to do, in such a situation - is simply to survive.