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Be Careful What You Wish For

September 2, 2012

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.

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Skin In The Game

April 8, 2012

We’ve all heard the saying “you get what you pay for.”  But in medicine, where the laws of economics don’t work like they do everywhere else, this maxim is essentially meaningless.  Thanks to our national health-insurance mess, some people pay very little (or nothing) out-of-pocket for a wide range of services, while others have to fork over huge sums of money for even the most basic of care.

Good arguments have been made for health insurance to become more like automobile or homeowners insurance.  Car insurance doesn’t cover oil changes and replacement tires, but it does pay for collisions and mishaps that may result if you don’t perform routine maintenance.  Homeowners insurance doesn’t pay the plumber, but might reimburse you for a flood that results from a blown valve on your water heater.

In medicine, we’ve never really seen this type of arrangement, apart from the occasional high-deductible plans and health savings accounts.  If you have a typical employer-sponsored health plan, not only do you pay little or nothing for your basic, routine care, but your insurance company has probably added even more services (massage, discounted gym memberships, “healthy eating” classes) in the name of preventive medicine and wellness.  (It’s almost as if your auto insurance paid for exactly what you’d do if you wanted to hang on to your car for 500,000 miles.)  When faced with this smorgasbord of free options, it’s easy to ignore the true underlying cost.  One way to reverse this trend is to ask for patients to put some “skin in the game.”

This might happen in Medicaid, the insurance plan for low-income persons.  California Governor Jerry Brown, for instance, proposed that patients receiving Medi-Cal (the California version of Medicaid) should pay higher co-pay amounts for care which is currently free (or nearly so).  A $5 co-payment for an office visit, or a $50 co-pay for an emergency room visit might sound hefty, but it’s a bargain—even for a poor family—if it means the difference between life and death… or even just sickness and health.

Unfortunately, California’s proposal was shot down in February by the Obama administration on legal grounds: the co-pays “are neither temporary nor targeted at a specific population.”  There are other legitimate questions, too, about its feasibility.  Would people forgo routine checkups or neglect to fill prescriptions to save a few dollars, only to cost the system more money down the road?  Would doctors and hospitals even bother to bill people (or send accounts to collections) for such low sums?  Is it fair to charge people money for what some people think is a right and should be free to all?

Without commenting on the moral and political arguments for or against this plan, I believe that this is a proposal worth testing—and psychiatry may be precisely the specialty in which it may have the greatest promise.

Psychiatric illnesses are unique among medical conditions.  Effective treatment involves more than just taking a pill or subjecting oneself to a biological intervention.  It involves the patient wanting to get better and believing in the path he or she is taking to achieve that outcome (even if it violates what the provider thinks is best).  Call it placebo effect, call it “transference,” call it insight, call it what you will—the psychological aspect of the patient’s “buying in” (pardon the pun) to treatment is an important part of successful psychiatric care, just as important—perhaps more so—as the biological effect of the drugs we prescribe.

Like it or not, part of that “wanting” and “believing” also involves “paying.”  Payment needn’t be extreme, but it should be enough to be noticeable.  Because only when someone has “skin in the game” does he or she feel motivated to change.  (Incidentally, this doesn’t have to be money, it could be one’s time, as well:  agreeing to attend an hour of weekly psychotherapy, going to self-help groups 2 or 3 times a week, or simply driving or taking the bus to the doctor’s office can mean a great deal for one’s recovery.)  It’s more than symbolic; it can mean a lot.

In my own life, I’ll admit, I took medical care for granted.  I was fortunate enough to be a healthy child, and had parents with good jobs that provided excellent health insurance.  It wasn’t until my mid-20s that I actually had to pay for medical care—even my co-payments seemed shocking, since I had never really had to pay anything before then.  Over the years, as I struggled with my own mental health needs (which were, unfortunately, not covered by my insurance), I had to pay ever-larger amounts out of my own pocket.  I honestly believe that this was a major contributor to my successful recovery—for starters, I wanted to get to a point where it didn’t make such a huge bite out of my bank account!

The absence of a “buy-in” is most stark precisely where Governor Brown wants to change it:  in Medicaid patients.  In the community clinics where I have worked, patients can visit the office with zero co-payment (and no penalties for no-shows).  This includes medication and therapy visits.  Prescriptions are often free as well; some patients take 4 or 5 (or more) medications—at zero out-of-pocket cost—which can set the government back hundreds of dollars a month.  At the same time, patients with no health insurance (or even with insurance, like me) can’t access the same drugs because of their prohibitive price tag or byzantine insurance restrictions.  It’s nowhere near a level playing field.

To make matters worse, patients on Medicaid generally tend to be more medically ill and, almost by definition, face significant environmental stressors that detrimentally affect their physical and mental well-being.  In these patients, we give psychiatric diagnoses far too liberally (often simply to give patients the opportunity to keep coming to see us, not because we truly believe there’s a diagnosable “mental illness”), and allow them to keep coming in—for free—to get various forms filled out and to refill medications that cost a fortune and don’t treat anything, perpetuating their dependence on an already overburdened health care system.  In fact, these patients would be much better served if we expected (and helped) them to obtain—and yes, even pay for—counseling or social-work assistance to overcome their environmental stressors, or measures to promote physical and mental wellness.

In the end, the solution seems like common sense.  When you own something—whether a home, an automobile, a major appliance, whatever—you tend to invest much more time and money in it than if you were just renting or borrowing.  The same could be said for your own health.  I don’t think it’s unreasonable to ask people to pony up an investment—even a small one—in their psychological and physical well-being.  Not only does it make good fiscal sense, but the psychological effect of taking responsibility for one’s own health may result in even greater future returns on that investment.  For everyone.


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