Be Careful What You Wish For

Whatever your opinion of the Affordable Care Act, you must admit that it’s good to see the American public talk about reducing health care costs, offering more efficient delivery systems, and expanding health care services to more of our nation’s people.  There’s no easy (or cheap) way to provide health care to all Americans, particularly with the inefficiencies and absurdities that characterize our current health care system, but it’s certainly goal worth pursuing.

However, there’s more to the story than just expanding coverage to more Americans.  There’s also the issue about improving the quality of that coverage.  If you listen to the politicians and pundits, you might get the impression that the most important goal is to insure more people, when in fact insurance may leave us with worse outcomes in the end.

Take, for example, an Op-Ed by Richard Friedman, MD, published in the New York Times in July.  The title says it all: “Good News For Mental Illness in Health Law.”  Dr Friedman makes the observations that seem de rigueur for articles like this one:  “Half of Americans will experience a major psychiatric disorder,” “mental illnesses are chronic lifelong diseases,” and so forth.  Friedman argues that the Affordable Care Act will—finally!—give these people the help they need.

Sounds good, right?  Well, not so fast.  First of all, there are two strategies in the ACA to insure more patients:  (1) the individual mandate, which requires people to purchase insurance through the state health-insurance exchanges, and (2) expansion of Medicaid, which may add another 11 million more people to this public insurance plan.

So more people will be insured.  But where’s the evidence that health insurance—whether private or public—improves outcomes in mental health?  To be sure, in some cases, insurance can be critically important: the suicidal patient can be hospitalized for his safety; the substance-abusing patient can access rehabilitation services; and the patient with bipolar disorder can stay on her mood stabilizing medication and keep her job, her family, and her life.  But there are many flavors of mental illness (i.e., not everything called “bipolar disorder” is bipolar disorder), and different people have different needs.  That’s the essence of psychiatry: understanding the person behind the illness and delivering treatment accordingly.  Individualized care is a lot harder when millions of people show up for it.

I’ve worked in insurance settings and Medicaid settings.  I’ve seen first-hand the emphasis on rapid treatment, the overwhelming urge to medicate (because that’s generally all we psychiatrists have time—and get paid—to do in such settings), and the underlying “chronic disease” assumption that keeps people persistently dependent on the psychiatric system.  This model does work for some patients.  But whether it “works” for all—or even most—patients seems to be less important than keeping costs low or enrolling as many people as possible for our services.

These demands are not only external; they have become part of the mindset of many psychiatrists.  I spent my last year of residency training, for instance, in a public mental health system, where I was a county employee and all patients were Medicaid recipients.  I walked away with a sense that what mattered was not the quality of care I provided, nor whether I developed treatment plans that incorporated people’s unique needs, nor whether my patients even got better at all.  Instead, what was most important (and what we were even lectured on!) was how to write notes that satisfied the payers, how to choose medications on the basis of a 20- or 30-minute (or shorter) assessment, and how not to exceed the 12 annual outpatient visits each patient was allotted.  To make matters worse, there was no way to discharge a patient without several months of red tape—regardless of whether the patient no longer needed our services, or was actually being harmed by the treatment.  The tide has definitely turned: tomorrow’s psychiatrists will answer to administrators’ rules, not the patients’ needs—and this generation of trainees will unfortunately never even know the difference.

The great irony in this whole debacle is that those who argue loudest for expansion of health care also tend to be those who argue for more humanistic and compassionate treatment.  In a similar vein, some of the most conscientious and compassionate doctors I know—many of them supporters of Obamacare—have deliberately chosen to work outside of insurance or Medicaid/Medicare altogether.  (I can’t say that I blame them, but isn’t that sort of like singing the praises of public education but sending your kids to private school?)  With more people obtaining mental health care through insurance “benefits,” the current model will become more widespread:  we’ll continue overprescribing unnecessary drugs to children and adults, institutionalizing people against their will even when less restrictive options may be more effective, offering lower reimbursements for psychotherapy and complementary services, and inviting practitioners with lesser training and experience (and whose experience is often limited exclusively to offering pills) to become the future face of mental health care.

Do psychiatry’s leaders say anything about these issues?  No.  When they’re not lamenting the lack of new pharmaceutical compounds or attacking those who offer valid critiques of modern-day psychiatry, they’re defending the imperfect DSM-5 and steadfastly preserving our right to prescribe drugs while the pharmaceutical industry is more than happy to create new (and costly) products to help us do so.  One solution may be to train psychiatrists to be cognizant of the extraordinary diversity among individuals who seek psychiatric help, to understand the limitations of our current treatments, and to introduce patients to alternatives.  While this may be more expensive up front, it may actually save money in the future:  for example, thorough diagnostic assessments by more seasoned and experienced providers may direct patients away from expensive office-and-medication-based treatment, and towards community-based services, self-help programs, talk therapy when indicated or desired by the patient, social work services, or any of a number of alternative resources geared towards true recovery.

Alas, no one seems to be offering that as an alternative.  Instead, we’re patting ourselves on the back for expanding health care coverage to more people and developing cost-saving initiatives of dubious benefit.  Somewhere along the way, we seem to have forgotten what “care” really means.  I wonder when we’ll start figuring that one out.

22 Responses to Be Careful What You Wish For

  1. Wow, you guys, docs, really have no clue about nurse practitioners–NP’s are like physicians–there are good ones and there are great ones and there are those that are a train wreck as psychotherapists, medications, etc. Training in medical school does not make a good psychiatrist and I have personal experience of having watched 100 plus psychiatrists do their thing since the 1980’s as a psychotherapist, doctoral trainee watching psychiatrists, working on psychiatric units as a clinician and now as an advanced practice nurse in psychiatry. We all and I mean all graduate from a program and if we get lucky to get a great residency and great training and then go on to get more training those that want to be great become great. Those that are not naturals, didn’t receive the additional training as psychotherapists become “midlevels” and this goes for physicians as well as nurse practitioners.

    I am an independent nurse practitioner with an expertise as a psychotherapist and I have an expertise in complex medications management working with refractory depression, Bipolar, Schizoaffective Disorder and I can manage independently. Collaboration is the ideal and I am independent and competent to manage complex cases independently all the while welcoming collaboration. Docs don’t want to collaborate with NP’s has been my experience.

    Anyways, take home message–don’t judge a book by it’s cover–NP’s are not just midlevels and there are those like myself who are experts in our field as evidenced by the patients we have managed, the patients got significantly better most of the time and some of us are experts as diagnosticians and psychotherapy!!!! Wow–can you believe that? Please keep open minds and hearts with one another and others different from yourselves. Mental health care is great with NP’s and Psychiatrists working collaboratively, independently and I do mean independently as NP’s and always welcoming new ideas.

    • dotdos says:

      I am a nurse working in the Spanish public health system, mental health. My experience is that psychiatrists (mostly) only care to diagnose and prescribe drugs. Unfortunately, there is no real teamwork. And, often, the benefits of nursing care are as important or more than drugs but … that’s life :-(

    • Puddytat says:

      Ms. Squires: How do you explain away or justify the current habit among m.h. “professionals” who base a “diagnosis” on the “basis” of a rather qucik 10 minute (at most) chit chat in an unnatural, uncomfortble setting?

      I ask this because this is what occured w/ me ten years ago at the psych e.r. I simply wanted someone to talk to; I was NOT, I repeat, NOT violent nor did I make ANY suuggestions or threats of such! I simply went there because I had no where else to turn…

      I was kept regardless, stripped, vaginally searched by male security staff (I’m still truamatized by this and maybe for life!), had my personal diary read aloud by said security staff 4 them 2 giggle tsk and gossip about…

      the next day, they discovered I wasn’t dangerous, but was pinned w/ the label “schizotypal” (in reality I have Asperger’s and the two have similar presentations)… However, the resident did this AFTER my OWn shrink gave her the correct info, my pdoc of a whopping TEN YEARS!!! So… a 10 minute chitchat is superior to the wisdom of a patient’s won doctor of ten years??? Interesting.

      After this type of experience I had w/ you guys in psychiatry, give me just ONE good reason to trust ANY of you guys or such facilities ever again?

      I’m waiting.

  2. Altostrata says:

    Dr Richard Friedman: “Half of Americans will experience a major psychiatric disorder” — doesn’t that sound like psychiatric disorders are the new normal??

    And the mental health industry grinds on and on….

    • mara says:

      Agree with Alto. Half the country is also overweight or obese. Sounds like cellulite is the new normal as well. Looks like this country needs to lose weight and work on their mental health…I wonder if the two issues are connected at all. Weight problems slow a person down, cause mood disturbances, hmmmm…

      You bring up good points about expanding care. Will it just make our situation worse? Will we just be expanding a system that doesn’t work? I have tried reading about politics of late, and I really don’t know how to vote in this upcoming election. So many intricacies. I hear about voucher systems, changing Medicare, expanding Medicaid, etc. I don’t know what to think anymore

      • Denise B says:

        My God, is there nowhere to escape fat hatred? The subject was psychiatry.

      • mara says:

        I don’t hate fat. I’m overweight and I don’t hate my curves of fattiness. I was agreeing with Alto that if half the country has something then that’s not some outlier. We don’t call being fat a disorder. Disorders are not normal. They are outliers. If they were normal then they wouldn’t be disorders, they would just be the human condition in the same way that sadness and grief are not disorders. Most people experience both of those issues, sometimes for months on end. This is what separates PMS from PMDD. Many women get PMS. Not too many get a disorder like PMDD. If half the country has something, that is kind of suspicious and hard to call a disorder. If half the country is mentally ill, then does half the country also have an eating disorder or metabolism rate disorder?

        And I do think that food and what what we put into our bodies affects our mental health. I can’t imagine all of the junk the average American consumes is good for brain chemistry. It’s been proven that the dyes in candy and sugary cereals cause hyperactivity in children. I could go on and on….It’s not about hating fat. Physical health affects mental health.

      • Altostrata says:

        I don’t believe “Half of Americans will experience a major psychiatric disorder”, Mara. I think that’s a gross exaggeration symptomatic of mental-health industry empire-building.

        That estimate has been creeping higher and higher year by year. Either modern life is driving people into “major psychiatric disorders” — which would indicate an entirely possible serious deterioration in society — or somebody is telling a bunch of whoppers.

        Since we have 30 years of whoppers from psychiatry, Occam’s Razor suggests that’s the source of estimated widespread abnormal woe.

      • mara says:

        “I don’t believe “Half of Americans will experience a major psychiatric disorder”, Mara.”

        I agreed with you in my post, Alto. That’s why I said mental disorders are not an outlier anymore than being fat is. Being fat is (usually) not considered a disorder. Lots of people pack on pounds (like half the country). Everyone has varying mood states. A disorder is an outlier.

        I have no clue how people could not read my sarcasm.

        Though I do seriously think that on some level food does affect our mental health. I am serious about that part. It’s not the fat part. I think a lot of people can be chubby and happy. It’s about not making our food toxic, because that can mess with our mental health as well as make us fat and diseased.

      • Denise B says:

        I did misread your sarcasm. A knee-jerk reaction without thinking because of my sensitivity about the issue of weight. Sorry about that.

  3. Hawkeye says:

    “One solution may be to train psychiatrists to be cognizant of the extraordinary diversity among individuals who seek psychiatric help, to understand the limitations of our current treatments,”

    You can’t do it. You are trying to tell a person who has wanted to be a doctor all of his/her life to be humble.

    The performance of most experts is evaluated rather carefully. Doctors? That point is flawed but suggestive maybe.

  4. Peter C. Dwyer says:

    Steve,

    I’ve just skimmed your piece so far, and will do it justice later. But this passage stood out:

    I spent my last year of residency training, for instance, in a public mental health system, where I was a county employee and all patients were Medicaid recipients. I walked away with a sense that what mattered was not the quality of care I provided, nor whether I developed treatment plans that incorporated people’s unique needs, nor whether my patients even got better at all. Instead, what was most important (and what we were even lectured on!) was how to write notes that satisfied the payers, how to choose medications on the basis of a 20- or 30-minute (or shorter) assessment, and how not to exceed the 12 annual outpatient visits each patient was allotted. To make matters worse, there was no way to discharge a patient without several months of red tape—regardless of whether the patient no longer needed our services, or was actually being harmed by the treatment. The tide has definitely turned: tomorrow’s psychiatrists will answer to administrators’ rules, not the patients’ needs—and this generation of trainees will unfortunately never even know the difference.

    Amen. This is a terrible problem in all areas of “mental health.” I was a social worker in treatment foster care for two years, and ran the program for another 9 years. When I started, I spent 25% of my time documenting and otherwise complying with procedural requirements; the rest of my time was spent with children and families performing in vivo therapeutic interventions and advocating for the kids.

    Before I retired this year, I asked the social workers how much time THEY now spend on paper work: I was astounded when they all said 75 percent. People laughed when I asked if they thought the paper work had improved our service to kids or families. All these check lists, rating scales and reports …

    My hat is off to these social workers, and to many others in “the system” who continue to care passionately about the people they serve under such conditions. But make no mistake – the current setup turns many in the system into functionaries who process people instead of attending to and caring about them, doing the bare minimum and passing them along to the next stop on the assembly line. This started long before Obama and most health care systems in the modern world would not turn around what now goes on in this country.

    • mara says:

      ???

      75% of their time was on paperwork? My goodness. Just imagine what school children will be saying on career day. I want to be a social worker like my Daddy so I can fill out tedious forms and manage paperwork most of the time and then spend a quarter of that time actually working with people.

      I don’t even want to know what they will say about psychiatry.

  5. […] Click here to read “Be Careful What You Wish For” by Steve Balt, MD from Thought  Broadcast on September 2, 2012. Explore posts in the same categories: Editorials […]

  6. Jay says:

    To add to Mr. Dwyer’s comments, my state imposes some truly ridiculous reporting requirements as a part of “mental health treatment.” We have to report whether a recipient’s children are serviced in other social service programs. Huh? Don’t those programs report their enrollments to the state? The latest mandate is to generate a cost-of-treatment statement based on the services that will be provided. What costs when Medicaid is billed. And just wait until they see how much it ‘costs’ to generate the treatment plan with all manner of truly useless questions. Way too much time and effort go into meaningless reporting activities which do not serve the client in any way.

  7. Altostrata says:

    Suggest doctors get in on the lobbying. This group will have a seat at the policy-making table.

    http://www.medpagetoday.com/Washington-Watch/ElectionCoverage/34621

    Doctors’ Group Pushes for ACA Support

    CHARLOTTE, N.C. — Of all the physician groups with a presence at the Democratic and Republican conventions, only one — Doctors for America — exists solely to push a political message: support for health reform.

    Doctors for America was started in 2009 with the mission to “advocate for our patients and for the common goal of creating a better healthcare system.” The group currently boasts 15,000 physician and medical student members nationwide, from a variety of political viewpoints…..

  8. Altostrata says:

    http://www.medpagetoday.com/PublicHealthPolicy/HealthPolicy/34606

    U.S. Healthcare Needs Revamp, IOM Says

    The American healthcare system needs to move from one that wastes hundreds of billions of dollars each year to one that provides the best care at a lower cost, according to a new report from the Institute of Medicine.

    To do that will require a shift to a “continuously learning” healthcare system that not only incorporates the latest scientific knowledge, but also patient preference, improved payment incentives, and better use of available technologies, said Mark Smith, MD, president and CEO of the California Healthcare Foundation and chair of the committee that wrote the report.

    “How is it possible that we spend more money on healthcare than any other country … and at the same time we do not attain the same results in healthcare outcomes and performance that others achieve?” Harvey Fineberg, MD, PhD, president of the IOM, said during a webcast press briefing at the National Press Club.

    The report estimated that $750 billion — about 30% of total U.S. healthcare costs — was wasted in 2009 on unnecessary services, excessive administrative costs, fraud, and other problems….

    • Hawkeye says:

      Just for fun I have been lately dividing the world of people into Axis I and Axis II. Dogs and Cats. The Axis I people are emotional and like to do stuff. The Axis II people like to be important. What’s happening is that the Axis II people are finding self important niches and imposing regulations on the very effective Axis 1 people. This makes the Axis I people important but results in a hell of a lot of inefficiency.
      I cannot parse what I seem to believe. People need freedom to act, that’s sort of right wing, but they need money to support their actions, that’s sort of left wing.
      My conclusion is that human society in the large is sort of hopeless.

  9. Hawkeye says:

    p.s. I meant, “Makes the Axis II people important but…..

  10. Hawkeye says:

    I am hopeless because the Rand types will obtain power and the non power grabbers like my reliable regular folks neighbors will only notice when it is too late.
    Spectrum psychopaths are like salt in soup. it doesn’t take much to ruin everything.

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