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 healthys 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 healthy 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 healthy  -- 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.    

Medicare: Access to Mental Health Care in Danger

In many states, Medicare fees are at the bottom of the barrel, prompting physicians and other health care providers to stop accepting new patients or even to opt out of Medicare completely. A recent proposal from MedPAC (Medicare Payment Advisory Commission, which makes recommendations to Congress) would further reduce rates by up to 38% over the next 10 years.

I wrote an article yesterday in Clinical Psychiatry News explaining this critical danger to the health care safety net for seniors, baby boomers, and people on disability.

I think Medicare needs to reinvent its game by moving away from per-visit payments -- which reward volumes -- toward payments based on severity-adjusted episodes of care combined with quality and outcomes multipliers -- which rewards quality and efficiency.

By re-inventing the way Medicare pays all providers, not by quantity but by quality and efficiency, it has a chance to bend the cost curve without making it harder for beneficiaries to find a doctor who will accept Medicare. Medicare enrollees deserve to be treated better. If Congress messes this up, there will be hell to pay at the ballot box.

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         Dinah added a post explaining what this might mean for patients at : http://healthyandmedic.blogspot.com/2011/09/what-medicare-cuts-may-mean-for.html

Collaborative Care: Fix It And Fix Mortality

I briefly scanned the Robert Wood Johnson synthesis report on mental and medical co-morbidity so I thought I'd summarize the highlights for the blog. If you'd rather watch the recorded web seminar you can hear it here.

The report relied on systemic literature review to look at the relative risk and mortality associated with co-morbid medical and mental health conditions. The looked at studies using structure clinical interviews, self-report, screening instruments and health care utilization data (diagnostic codes reported to Medicaid).

This is what they found:

• 68 percent of adults with a mental disorder had at least one general medical condition, and 29 percent of those with a medical disorder had a comorbid mental health condition
• These findings support the conclusion that there should be strong integration of medical and mental health care
• Psychiatric disorders were the most expensive conditions to treat among Medicaid beneficiaries, but also the most common when combined with cardiovascular disease
• Medical conditions and psychiatric conditions have a reciprocal risk relationship: having one disorder increases the risk for having the other
• Both medical and mental disorders are associated with low income, poor education, early childhood trauma and chronic stress
• Four modifiable risk factors are responsible for high rates of co-morbidity: alcohol and drugs, tobacco, poor nutrition and lack of exercise
• The treatments themselves may worsen co-morbidity (somatic meds cause psychiatric side effects, psychiatric meds may cause or worsen medical conditions)
• Public mental health clients die 25 years earlier than the average life expectancy (see Figure 4 above for the relative risk of six common psychiatric conditions)
• Multidisciplinary team approach to treatment is most effective: fully integrated medical, mental health and substance abuse services

So instead of having a public health care system that is fragmented between freestanding clinics, we should have integrated clinics that follow a collaborative care model and that provide a broad range of services. For me this means that we can no longer afford to have disjunction of care between state agencies: correctional facilities and public clinics need to coordinate care for both medical and mental health conditions. This study describes my typical clinic population: poor, poorly educated, sick, traumatized and under chronic stress. They are at greater risk of dying and the most costly to care for.