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.  
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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.  

Dinah

2 comments:

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.