Published in the March/April 2006 issue of MetroDoctors (The Journal of the Hennepin and Ramsey Medical Societies) Volume 8, No. 2 pp 7-9
Q: As it pertains to Psychiatry and Mental Health, how would you recommend we proceed to give the public access to information on the cost and quality of their care?
A: The public is well aware that health care insurance premiums are on the rise faster than other costs. When mental health or substance abuse services are sought, one rapidly learns that outpatient psychiatric services are often restricted by insurance management carveout arrangements, high patient deductibles and copayments, and provider networks which queue patients. This results in long wait times to see psychiatrists for brief visits, poor care planning and case coordination between mental health providers and with treating (PCP) physicians, and little respect for the value of doctor-patient care continuity. Moreover, insurance payments favor medication prescribing by psychiatrists and other physicians, and a “split therapy” paradigm of medication checks by physicians with psychotherapy by psychologists and social workers. There is simply no evidence that this paradigm as current insurance industry standard provides optimal clinical results or cost-effective psychiatric/mental health care. To remedy this, we must implement strategies to make a provider’s psychiatric services accountable to their patients, and that patients must direct the flow of payment dollars for their care. Strategies to accomplish this include: 1. Terminating restrictive insurance company provider agreements. Most are onerous. 2. Strict policies on privacy and confidentiality of medical records and patient information. 3. Promoting individual provider and clinic practice websites to advertise mental health provider accessibility, qualifications, and fees. This will encourage provider competition and visibility.
Q: Please comment on the collaborative role of the mental health disciplines (psychiatry, psychology, clinical social work, mental health nursing) in providing comprehensive evaluations and patient specific treatment. Do we need working models for this approach to care and measures of effectiveness and cost that is provided to patients?
A: The real problem is not the professional training of psychiatrists, primary care physicians, ER docs, nurses, psychotherapists, and alcohol/drug counselors. We are fully able to use the telephone, FAX machine, and mail to communicate, and regularly do whether we are paid to do so or not. This is simply good medicine and good health care practice. However, most of us are now tied into multiple and rigid reimbursement systems which actively discourage our collaborative efforts on behalf of patients. Over the years I have evaluated models of nurse and/or social worker case management, crisis intervention, primary care integration, and urgent care evaluation in the hospital ER. All of these initiatives work when there is financial support and provider buy in — until the grant runs out. So, I don’t think we will find systems models of collaborative care that will solve the current crisis in mental health care access and delivery. Moreover, most case-management and disease management activity at the health plan or insurance company level actually distances the patient and provider from ongoing, individualized, care planning and mutual accountability. We need a paradigm shift to empowering individual clinicians and clinics to do what works and is right for patients. This will happen when patients and their families direct the money, and when providers compete on price and quality.
Q: What is the best format/venue for informing patients about the quality and cost of medical services? – many are disinterested or believe the issue is too complex to understand, and physicians are very sensitive about widespread release of quality data.
A: First, it is simply untrue that patients and their families cannot understand information about the costs and quality of medical care. Certainly there is a time and place to evaluate medical care cost and quality, and this is not when one is on the way to the ER in the ambulance. Second, regarding physicians being concerned about the widespread release of “quality” data from the government or insurance companies, the general public and the physician community have every reason to be concerned! Population-based data comparing clinics or health care systems in Minnesota are not adjusted for illness severity or other patient characteristics. In addition, there is a misplaced hope that electronic medical records coupled with evidence-based treatment guidelines will differentiate quality clinics and physicians. Add to this imperfect storm pay-for-performance financial incentives based on flawed assumptions and data. Every physician in Minnesota should have a website that describes his or her experience, training, practice scope and fees. There are many formats and venues for conveying quality information to patients: A collaborative relationship with one’s doctors (the “Medical Home” concept), actual experiences of relatives and others with the provider or clinic, advocacy organizations (for psychiatric services, the Minnesota Alliance for the Mentally Ill and Mental Health Association of Minnesota), peer reviewed literature and Internet sites such as those of the Mayo Clinic and Johns Hopkins, and national professional association treatment guidelines. Regarding cost information, one should via the Internet have access to and compare provider fees and allowable insurance payments for medical services. Also one should have access to detail on insurance contracts coverage and costs on line.
Q: Do you see overuse of psychiatric services a bigger issue than underuse or vice versa? How do you see the move to consumer-driven health care influencing overuse/underuse?
A: The notion of over-utilization of psychiatric services is simply false. This is has been a rationalization for cutting mental health and chemical dependency services over the past two decades. Managed care has reduced mental health outlays from about 7% of health care expenditures in 1985 to 2-3% now. Moreover, 20-40% of insurance dollars go to managing the care, i. e. administrative costs for external or internal behavioral carveout organizations working for the parent insurance entity to control mental health spending.
Q: How do we improve access to adequate psychiatric care for patients in the Twin Cities; particularly those who need chronic care?
A: Improve the pay to those who provide it. Use as the quality measuring tool the actual experiences of patients as reported to advocacy organizations such as Minnesota Alliance for the Mentally Ill (NAMI-MN) and the Mental Health Association of Minnesota (MHAM). Publicize, critique, and analyze problems and innovative approaches to psychiatric services care access and quality. Advocate reform of the present discriminatory payments system for mental health; for example, for the disabled and elderly patient, Medicare pays 50% of $113.17 allowable for 50 minutes with a psychiatrist. Our private insurance systems and Medicaid mental health carveouts follow suit with Medicare.
Q: How have you modified your release of psych information based on HIPAA requirements?
A: I am more stringent in protecting privacy than is required by the current HIPAA regulations. Specifically, I do not release information about my patients to any third party without their explicit, case-specific consent for the release. I will submit insurance forms for them if they request me to do this, but I will offer only information needed to process the claim — usually diagnosis and treatment code.
Q: Recognizing that there is a shortage of behavioral health resources in the community, how can primary care get more “up to speed” in the management of behavioral health issues?
A: I am very impressed with the interest and mounting skills of many primary care colleagues. But more needs to be done to help improve the primary care of patients with mental and substance-related disorders.
Q: What can we do to encourage more medical students to consider psychiatry as a career choice?
A: Support the able efforts of the University of Minnesota Department of Psychiatry, Mayo Clinic, and create clinical teaching mentorships for students and residents with practicing community psychiatrists. The Minnesota Psychiatric Society has a strong and nurturing Women’s Psychiatry Committee, for example.
Q: What can we do to help reestablish behavioral health as an essential component of good, overall patient care, especially for patients with chronic or complex medical needs?
A: Actually, I do not like the term “behavioral health” because it overlooks the presence of motivation, emotion, and cognition in almost all aspects of medical care. Also, psychiatrists are physicians and often detect problems which require the attention of other physicians. We know what to do to practice good psychiatric medicine. This includes the valuable contributions of psychologists and others. Are doctors willing to step up to the plate and help their patients get quality psychiatric services? I think so.
Q: You have long been a pillar of quality psychiatric care. For over 30 years you have maintained an independent practice which among many specialties has become rare. How do you see the future for psychiatry, family medicine, and other primary care specialties?
A: I hope to contribute to these discussions in the future. We, as professionals, are valuable to our patients. Just ask them.
Q: You have a long and distinguished history of critiquing insurance companies and mental health carveouts. Do you feel that a single-payor (public) system would obviate all carveouts, and what are the advantages/disadvantages to the mental health consumer/provider of such a system?
A: No, I do not see a single payor as a panacea at all. We do in fact have single payor for most severely mentally ill patients now — Medicare and medical assistance. I favor allowing patients more control of where these dollars go in our public and private systems, am very concerned that we as a society have shirked our responsibility to this vulnerable population, and I strongly urge professional and public advocacy for mentally ill patients — to include their housing in the community.
Q: What might you see as appropriate responses/plans from organized medicine to address what I see in my practice of emergency medicine as a crisis in the provision of psychiatric services for both inpatients and outpatients? Not only finding beds for those with unstable psychiatric emergencies, but also arranging care for those who need outpatient evaluation and care has become harder and harder over the years. Yet, patients and/or their families expect that these services will be available (and reasonably so) and often they’re not, at least in a timely fashion. How desperate does it have to get before it gets better?
A: Emergency medicine physicians are faced with daunting challenges concerning the evaluation and disposition of mentally ill and substance using patients. ER docs are doing the right thing by insisting on more support in the ER for psychiatric evaluation services under your control. Certainly mental health nurses are a part of the solution. ER doctors and their staff want access to psychiatrists. You are successfully approaching hospital administrators and government payors about the ER and short term psychiatric bed crisis in the Twin Cities and in greater Minnesota. The MMA and Minnesota Psychiatric Society strongly support these efforts. We clearly need to encourage more psychiatrists to take on new patients and negotiate collaborations, for example, with mental health centers and hospital triage.
Q: How should practicing physicians respond when health plan or disease management sponsored case or disease managers (with informed consent; psychiatry or otherwise) contact them about helping to facilitate improved clinical outcomes for one of their patients?
A: Collaboratively and also with skepticism. The patient should first be informed of insurance case management activities and give his consent. Patient inquiries about cost and accountability to all parties, including the insurance company, are always appropriate. The doctor, clinic, or mental health center is the real venue of care rather than a health plan or insurance company.
In this interview I seek to:
- Promote the private practice of psychiatry and other medical specialties as a counterweight to current over-dependence on restrictive insurance company and health plan provider networks which limit patients’ access to physicians and discourage healthy competition among health care providers.
- Disclose provider fees and allowable insurance payments to patients and their physicians, so that patients in partnership with their physicians become knowledgeable purchasers of care services and insurance products.
- Advocate that all Minnesota physicians create and maintain a website to make available to the public information about their professional interests, credentials, and fees.
Lee Beecher’s Website is an example of such a free doctor website available now through medscape/WebMd.