One Dad's Perspective

Okay, while our presidential candidates are debating, I thought I would link to an article by a former state legislator.  In "How I Helped Create a Flawed Mental Health System That Failed Millions -- and My Son," Paul Gianfriddo talks about his decades-long attempts to help his ill son, a young man who sounds to have mental health and educational needs that couldn't be met by a system with limitations.

Gianfriddo writes:

The 1980s was the decade when many of the state’s large psychiatric hospitals were emptied. We had the right idea. After years of neglect, the hospitals’ programs and buildings were in decay. But we didn’t always understand what we were doing. In my new legislative role, I jumped at the opportunity to move people out of “those places.” Through my subcommittee, I initiated funding for community mental health and substance abuse treatment programs for adults, returned young people from institution-based “special school districts” to schools in their hometowns, and provided for care coordinators to help manage the transition of people back into the community. 

But we legislators in Connecticut and many other states made a series of critical misjudgments that have haunted us all ever since. 

First, we didn’t understand how poorly prepared the public school systems were to educate children with serious mental illnesses in regular schools and classrooms. Second, we didn’t adequately fund community agencies to meet the new demand for community mental health services—ultimately forcing our county jails to fill the void. And third, we didn’t realize how important it would be to create collaborations among educators, primary care clinicians, mental health professionals, social services providers, and even members of the criminal justice system, if people with serious mental illnesses were to have a reasonable chance of living successfully in the community. 

During the twenty-five years since, I’ve experienced firsthand the devastating consequences of these mistakes.

The story about his son is heart-breaking and there is no happy ending.  I'll leave you to read the whole article and see what you think.  And if you'd like to check it out, Mr. Gianfriddo blogs, often about mental health issues, at Our Health Policy Matters.

The Bestest Cheapest Care Possible

If you've been hanging out here on Shrink Rap for the past few days, you know we've been talking about how the healthcare dollar gets spent.  Do capitated systems (coverage for all with a single pot of moo-la) make it harder to get services?  Our readers say "No."  Do fee-for-service systems inspire doctors to order more and more services so they make more and more money at the mercy of the helpless patient and the poor insurance company?  Are psychiatrists who do psychotherapy a total waste of money when cheaper professionals could do the same job?  

Some of the questions that have come up in our comments section imply that there are precise answers to these questions.  There aren't.  In situations where there are protocols, there is no issue, in any system, the protocol is followed for any patient who enters the arena.  It's where stuff gets foggy that the questions get raised.  Let me walk you through some examples.

Jim is eating breakfast with his wife.  She is a Democrat and he is a Republican.  Sesame Street comes on and Jim's wife starts to cry, Romney will obliterate Big Bird if he is elected.  Jim wants to put in his two cents, but suddenly, he can't get the words to form.  He tries to speak, and nothing makes sense.  One of his arms isn't working, and one of his legs isn't working.  Cookie Monster comes on, Jim's wife refocuses her attention to the conversation they were having over bacon and eggs, and she realizes that something is horribly wrong.  She calls an ambulance and Jim is brought to the hospital.  There is no question that Jim will be seen by a doctor, probably fairly quickly, and sent for a brain scan.  No one will ask if the scan is necessary, his insurance company will not deny it, and even if he is poor and uninsured, he will have the brain scan.  Who will get the bill is another story, but this will happen no matter where he is.  Beyond that, I don't know what the options are.  It doesn't matter if the system is capitated or fee-for-service, and the ED doctor is paid a salary and he makes no more or no less for ordering a brain scan.

Bill is having awful headaches.  His doctor doesn't know why.  He does a neuro exam and it is normal.  He asks Bill lots of questions.  There is nothing that indicates that these headaches are any thing other than tension headaches, and they don't occur in the early morning or with have any nausea or vomiting with them, there are no scotoma, there is nothing to indicate that something awful is going on.  Still, Bill is 43 and he's never had headaches before and his doctor feels uneasy.  He'd like to order a brain scan, but with a negative neurologic exam and no indicators of a mass or trauma, there is not a clear indication to order an expensive scan.  In a system where his doctor must either justify his decision for the scan (fee-for-service managed care), or have money taken out of the big pot that serves everyone,  Bill won't get the scan.  Does it matter, does Bill need the scan?  Well, if an operable lesion is found (a tumor, an circulatory malformation, increased pressure) then it was needed.  If nothing is found, then the scan was reassuring but unnecessary.  Do note, that obtaining the scan does not put any money in the doctor's pocket unless he has some interest in the radiology center (this is not likely).  

So would it change your opinion of whether he needs the scan if I told you that I know someone with headaches and no other symptoms who had a malignant brain tumor -- discovered because his doc got the scan that wasn't indicated?  If Bill's doc knew someone with that story, he'd really want to get the test done.  Would it change your mind if I told you I know a man who told his doctor for years "There's something in my head."  Years.  There was a large, benign,  slow-growing meningioma finally discovered.  So does everyone need scans?  Does it matter?  The man who had "something in my head" for 7 years had his tumor removed and did fine.  The woman who's doctor jumped on ordering the scan for the headache told the patient it wasn't urgent and she got the scan a few weeks later.  That end of that story is rather tragic. 

Finally, John is absolutely tortured, he can't sleep and he's hearing voices and he's acting really strangely.  John's psychiatrist diagnoses the psychotic disorder of your choice and wants to start a medication.  Which medication?  Let's be real, there are no good choices.  We could try one of the old medicines.  Haldol works well and it's cheap.  Oh, did anyone mention that patients hate taking haldol, that back in the day when the old neuroleptics were all we had to offer, that people had to be coerced into taking them and they used to say it felt like molasses had been poured into their brains. They walked stiffly, their eyes rolled up into their head during dystonic reactions and they drooled.  And in 25 years, 68% of them got tardive dyskinesia.  

Okay, we'll skip the Haldol, because everyone does.  Let's try a newer medicine.  Zyprexa works really well for psychosis and it's well tolerated.  It's an older medication and it only costs $1000/month to be on the generic (I kid you not).  Oh, and of all the atypicals, Zyprexa is the most likely to be associated with weight gain and metabolic changes and John is already overweight and his cholesterol is a bit high, and his father had a heart attack at a young age and has diabetes.  Let's avoid Zyprexa for now.   Risperdal might be a good choice, and it only runs about $50 a month for a low dose if you shop around.  Oh, but John is really worried about this weight gain and diabetes risk, and he says he wants the medication with the lowest risk of weight gain and diabetes.  That would be Abilify, which comes in at roughly $500/month.  John wants that, and he says he has a $25 dollar co-pay and he wants the minimal risk of weight gain and diabetes.  But really, his psychosis is bad, Zyprexa probably works best, and not everyone gains weight and gets metabolic abnormalities on it: the issue is one of risk.  If he does get diabetes, the cost of his care increases dramatically.  So does a patient have the right to request the safest medication, even if it will cost the taxpayer $450/month more (Abilify versus Risperdal)?  What's the easy answer here?  And if he takes a less effective antipsychotic and ends up in the hospital it will run roughly $1700/day, so it might be most cost effective to avoid that.  Just so you know, if the patient has Medicaid in Maryland, the government does not allow the first trial to be with Zyprexa (costs too much with the metabolic risk) or Abilify (too expensive).  John may want the least risk, but Uncle Sam (or Uncle Martin?) just says no.

What Makes for Better Care: Capitation or Fee-For-Service?

In the United States, most medical is rendered on a fee-for-service basis.  The more often you come in, the more money I make (at least from you).  In theory, it motivates doctors to recommend more services, and it motivates insurance companies to bargain for very low payments and to deny services.  Another form of payment is what the HMO's do -- a population is defined and a medical system is given a certain amount of money is divided to provide treatment for those patients.  This form of reimbursement gives doctors the ability to divide the money pot in such a way that the neediest get the most, but it also encourages doctors to offer less care to any given patient.  In such a system, doctors are generally rewarded if there is money left over and penalized if they go over the budget.  Incentives may be put in place to encourage good outcomes.

Mental health treatments are often different from other forms of care in that the medications can be very expensive (okay, there are other expensive medicines that run circles around us, but as frequently-used meds go, Cymbalta and Abilify are money drains) and psychotherapy is a time intensive treatment where there are no absolute standards that determine who comes twice a week versus who comes twice a year.  Capitated systems don't typically (?ever) pay for psychotherapy by a psychiatrist  -- the kind of work I do -- and they don't typically allow for on-going weekly psychotherapy sessions, unless it's felt this is absolutely necessary to prevent a more costly hospitalization.

What system are you covered under?  What do you think works best and why?  Obviously, I interested in hearing from our readers outside the United States.    

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.

On Health Care Reform: Stolen from the APA's Announcements

Verbatim:

Moments ago, as expected, the U.S. House of Representatives approved H.R. 2, legislation to repeal last year's health reform law. The final tally was 245-189, with 3 Democrats joining Republicans to vote for repeal. No House Republicans voted against repeal. The impact of the vote appears to be largely symbolic, since Senate Majority Leader Harry Reid (D-NV) has already said he will not bring the bill to the Senate floor for a vote, and it appears unlikely that Senate Republicans will be able to attract enough Senate Democrats to force a vote. Even if the Senate does approve H.R. 2, President Obama has already indicated that he will veto the bill, and there are insufficient votes in Congress to override a veto should it occur.

Tomorrow, the House is scheduled to debate legislation that instructs key committees to develop proposals to replace the reform law. While the President has indicated he is not opposed to modifying existing law, it is difficult to predict how likely such action is to succeed. In the meantime, the House GOP majority is also expected to seek to defund or otherwise delay implementation of the law. Numerous court challenges to the law remain in process and most likely will be up to the Supreme Court to resolve.

Health Care Reform and Mental Health--stolen from Kevin MD

Who could follow the Obama Health Care reform debates? Thousands of pages and emotions flying high, and it all became a partisan fiasco, where the patients got lost in the reams.

So Kevin MD --- links to How Heath Care Reform Will Affect Mental Health-- a post by blogger Diane Lee at Somebody Heal Me. It's a hopeful and optimistic post about how reform will increase the number of insured, increase access to treatment and medications, shrink donut holes, prevent insurance companies from refusing to insure those with mental illness, and do overall good things for the country. I like optimism.

Are you feeling hopeful?

ObamaMama it's Health Care Reform!

In case you haven't heard, we've got ourselves health care reform.
What do you think?
Will this be a good thing for psychiatric patients?
Will this be a good thing for psychiatric docs (the shrinks among us?)

Personally, it's been so much commotion and so many pages, it's been way too much to follow (and no one asked my opinion anyway). I think I'm happy for movement, we've been stuck for so long with a system that just doesn't make sense. I'm told most people are happy with their health insurance. Are you?

Go for it, write in our comment section!

Flower for Patients

A group of internet friends (what do you call people you know only via the net? peeps? tweeps? there have to be better words) have been talking over the last couple weeks (via Google Wave and also on Posterous and Skype about what we've been calling "Flower" or #hcflower on Twitter) about the changes that need to occur to reform health care.  One of the revolutionary -- and critical -- changes needed is the recognition that patients need access to their health data.  They not only have a right to access it, but should own it and be able to license access to it.  For a particular purpose.  For a particular period of time.  To particular individuals or organizations (my doctor, my hospital, my insurance company, my wife, my tweeps).

But that is not being much discussed in Washington.

One of these friends is Gilles Frydman, who also founded ACOR.  Click on his post on Open Streams and Fax Machines below.

-via Gilles Frydman on e-patients.net

---

"Close to $2.5 trillions have been spent on health care since President Obama announced his decision to reform the health care system. A year later, as expected,  all the talk in Washington remains about:

• the end/restart/end-again of the public option
• the expected final/interim/temporary definition of “meaningful use”
• the amount of savings/taxes/additional expenses
• move from FFS (I really mean Fee-For-Service) to PFP and
• comparative effectiveness/death panels/healthcare rationing

Have you heard ANY politician talk about patient/individuals empowerment in relation to health care reform? I have not! Health care reform is still 100% about reimbursement reform and 0% about social innovation. No surprise when individuals so often experience dehumanizing events when they interact with the medical system."  [more]

---

[photo credit: bestrated1 via Flickr]