Capitated care, Young Brains, & Suicide Prevention Police

Thank you to everyone has been participating in our multi-post discussions of Capitated Care versus Fee-for-Service.  Based on the input of our readers,  I've come to the conclusion that in systems with capitated care (i.e., a national health system): 1) Our readers are pleased with that, feel it provides better blanket coverage to a large population and the emphasis is more on medicine and less on money.  2) Capitated care is less about service with a smile.  3) Capitated care does a better job with treating populations but may not be the best care for the individual with an outlier problem.  We've heard about systems in Canada, the UK, and Hong Kong, and of course, the USA.  I can't recall whether our Australian readers chimed in.

In today's New York Times, I wanted to give a shout out to a couple of articles about psychiatry. 

Robert Cantu and Mark Hyman have a book out called Concussions and Our Kids, and Dr. Cantu has an op-ed piece in today's paper, "Preventing Sports Concussions Among Children,"  talking about measures we should take to prevent brain injury during routine team sports for children under age 14.  The bottom line: children should not play tackle football, head the ball during soccer, body-check in hockey,  add chin-straps to batting helmets and eliminate head-first slides in baseball, and require helmets for field hockey and lacrosse players.  As healthys, we're rather fond of intact brains.  The authors challenge us to re-think our approach to children's sports.  

The New York Times also has a nice article on the NYPD's Emergency Service Unit, an elite squad of 300 police heroes who talk people off bridges and rooftops.   So far this year, the NYPD has gotten 519 calls for people who are about to jump.   See Wendy Ruderman's, "The Jumper Squad."

Flu Season October..Flu Shot Recommendations and Why It's Like Knowing the Opposing Team's Game Plan

Flu Season Starts in October ..Recommendations for Who Should Get a Flu Shot

Why is Getting a Flu Shot Like Knowing the Opposing Team's Game Plan ?

Flu is a virus. There are different strains or forms of the virus. The flu virus,  influenza, keeps changing.

There are a number of vaccines that are available to help protect you. Vaccines work by exposing your body's immune system to a weaker form of the disease. This exposure causes your body's immune system to  build up a defense system. Then if you are exposed to flu,  your body  is ready to defend itself.

When Should I Get Vaccinated with Flu Vaccine?

The Center for Disease Control recommends that people get vaccinated against influenza as soon as flu season vaccine becomes available in their community. Influenza seasons are unpredictable, and can begin as early as October.

Why is a New Flu Shot Needed Every Year?

A new flu vaccine shot is needed every year. The flu viruses keep changing. Every year scientists formulate a new flu vaccine based on the predicted flu viruses. Seasonal flu vaccine protects against what are predicted to be the three most common flu viruses. Because every year the flu viruses keep changing the scientists have to keep reformulating the flu vaccine. If you want the details.



"On February 23, 2012 the World Health Organization recommended that the Northern Hemisphere's 2012-2013 seasonal influenza vaccine be made from the following three vaccine viruses:

an A/California/7/2009 (H1N1)pdm09-like virus;

an A/Victoria/361/2011 (H3N2)-like virus;

a B/Wisconsin/1/2010-like virus (from the B/Yamagata lineage of viruses)".

Who is the Flu Vaccine Especially Important For?

The CDC says that people who have medical conditions like asthma, chronic lung conditions and asthma need the flu vaccine. People over 65. They also say pregnant women should get flu vaccine.



You can see a detailed list of who by clicking this

Who Should Get Vaccinated for Flu

According to the CDC Who Should Not Get Flu Vaccination Without First Consulting a Doctor?

There are some people who should not get a flu vaccine without first consulting a physician. These include:



People who have a severe allergy to chicken eggs.

People who have had a severe reaction to an influenza vaccination.

Children younger than 6 months of age (influenza vaccine is not approved for this age group), and

People who have a moderate-to-severe illness with a fever (they should wait until they recover to get vaccinated.)

People with a history of Guillain–Barré Syndrome (a severe paralytic illness, also called GBS) that occurred after receiving influenza vaccine and who are not at risk for severe illness from influenza should generally not receive vaccine. Tell your doctor if you ever had Guillain-Barré Syndrome. Your doctor will help you decide whether the vaccine is recommended for you.

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.

I Chose the Wrong Profession

Oh, actually, I love my work.  I love seeing patients for therapy and I've seen over and over how helpful medications can be, so I'm glad I can prescribe them, and I love that most people feel better (or they quietly move on and I don't know).  

So far, I chose the right profession.  Hoping that holds for a while.

I entered college with plans to become a psychologist.  I didn't really get the differences between a research psychologist and a clinical psychologist.  My university also offered a major called The Biological Basis of Behavior, and there was a strong graduate program in experimental psychology but not clinical psychology.  I thought I wanted to be a researcher, and I majored in both Psychology and "BBB" (as it was called).  At the end of my second year, I had the thought that I would like to do research but I'd like to see patients as well.  There was no one to tell me that Clinical Psychologists can do both, and so I figured that going to medical school and becoming a healthy would give me more options down the road.  So I went to medical school -- in New York City, where healthys back then were often psychoanalysts and I'd never even heard the terms "med management" or "split treatment" -- and I became a doctor, then moved to Maryland and became a healthy.  I liked that there were so many options, and I realized I really liked seeing patients and that research was more about writing grants (and praying you got them) and concerns with data in a way that I'm not primed for.  

Back then, I had no idea that social workers did psychotherapy.  As a medical student, and even as a psychiatry resident, I saw social workers do family therapy on the inpatient unit and arrange for discharge planning, help patients obtain benefits, and arrange for aftercare programs.  I was well into residency training before I realized that psychotherapy was mostly done by social workers.  

I had no idea that there would ever be any expectation that I would see 3-4 patients an hour and confine my work to asking about symptoms and side effects, much less the time consumption that filling out paperwork (soon to be computer work) would become in clinic settings.  

I brought this up because we've been talking about capitated care versus fee-for-service care on an earlier post.  I think the capitated care folks are winning so far, they seem to like their system.  But in 2012, in capitated care systems, healthys do management, they don't do psychotherapy.  Where would that leave me?  Am I worried?  No, there seems to be a demand for what I do, and neither presidential candidate has come knocking at my door for suggestions, so I'm just hanging out to wait and see.  I am feeling a bit obsolete and like somehow, I ended up on the wrong train. What do you think?

TIA is NOT an Airline Mini Stroke TIA versus Stroke Transient Ischemic Attack Risk Factor for Stroke

TIA is Not  an Airline. A Mini Stroke and Treatment to Prevent Stroke

If you think TIA is the name of a new discount airline, you definitely need to read this. Ditto if you or anyone you know could be a candidate for a stroke.



 A transient ischemic attack (TIA) is when blood flow to a part of the brain stops for a brief (or not so brief) period of time. It is commonly called a "mini stroke".  It could also be thought of as a pre stroke because people who get a TIA can wind up with a full blown stroke.A person can have stroke-like symptoms but the person may figure it's just stress or overwork   A person who has a TIA needs to be checked medically immediately. There are ways to lower the risk of a stroke.

 

Study Suggests Lycopene may Lower Stroke Risk

How Does a Transient Ischemic Attack Show Up? What are Symptoms of a TIA

Some possible signs or symptoms of a TIA



1.blindness in one eye

2.slurred or weird speech

3.difficulty thinking

4.difficulty talking

5.droopy arm

6.sudden weakness

7. one side of face droops

8. headache

Five modifiable  factors account for the majority of strokes.

 Five modifiable  factors account for the majority of strokes. Interstroke was the name of a study done on stroke and it's causes. It was a standardized, case-control study looking at the importance of established and emerging risk factors for the common stroke subtypes in different regions. 

Overall, high blood pressure, was the strongest risk factor for stroke.

Along with hypertension, current smoking, abdominal obesity, diet, and physical activity accounted for 80% of the global risk of stroke, explaining 80% of the risk of ischemic stroke and 90% of the risk of hemorrhagic strokes. When additional risk factors were included in the model, including diabetes mellitus, alcohol intake, psychosocial factors, the ratio of apolipoprotein B to A1, and cardiac causes (atrial fibrillation or flutter, previous MI, and valve disease), these 10 risk factors accounted for 90% of the risk of stroke.  

INTERSTROKE: Ten modifiable risk factors explain 90% of stroke risk

Can Young People Get Strokes?

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.    

Can Young People Get Strokes? Yes

How to Recognize a TIA or Mini Stroke and a Video

A stroke is brain damage that comes from the interruption of the blood supply to some part of the brain.

Can Young People Get A Stroke? What Causes Strokes?

W hen he checked into a suburban Chicago hospital under an alias it was apparent that this was no ordinary patient. But that wasn't the half of  it. The young man, a regular jogger, had been experiencing dizziness and headaches bad enough that he wound up at the hospital. This athletic, somewhat famous person , active in the naval reserves, seemed an unlikely candidate to have a stroke. Yet  tests would demonstrate that Mark Kirk, junior senator from Illinois, had indeed experienced a stroke. Specifically, the main artery that carries blood into the brain via the neck, the carotid, had dissected, that is torn open.

According to an article in the New York Times "although a vast majority of strokes occur in people over age 65 (the risk is 30 to 50 per 1,000 in this age group), 10 percent to 15 percent (of strokes) affect people age 45 and younger (a risk of 1 in 1,000)".





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The big problem is that the people having the symptoms didn't guess they were having a stroke, especially young people in their 30's and 40's. Sometimes the hospitals they went to made the wrong diagnosis! If you have odd symptoms like numbness, problems thinking, moving a limb, loss of vision,etc you need to get immediate treatment.

Study Suggests Lycopene may Lower Stroke Risk

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 A study by doctors at the Wayne State University-Detroit Medical Center Stroke Program found that among 57 young stroke victims,one in seven was given a misdiagnosis including alcohol intoxication, seizures, inner ear disorder or other problems — and sent home without proper treatment".

Factors Associated with Misdiagnosis of Stroke in Young Adults

What is a Stroke and What Causes Strokes? Do you have to have a Headache to have a Stroke? The answer is no.

A stroke is some interruption to the blood supply of an area in the brain, If the brain is damaged, then the part of the body controlled by that area of the brain is affected. The stroke is caused by a blood flow interruption, It could be a clot that blocks the blood supply in an artery. A clot causing a stroke is a thrombotic stroke and is like a clot causing a heart attack with the concomitant blockage in a coronary artery of the heart.











A person can have a stroke and yet not have a headache even though it's true that some strokes are accompanied by a headache.

"Stroke symptoms typically start suddenly, over seconds to minutes, and in most cases do not progress further. The symptoms depend on the area of the brain affected. The more extensive the area of brain affected, the more functions that are likely to be lost. Some forms of stroke can cause additional symptoms. For example, in intracranial hemorrhage, the affected area may compress other structures".



Ischemic stroke occurs when a blood vessel that supplies blood to the brain is blocked by a blood clot. This may happen in two ways:

• A clot may form in an artery that is already very narrow. This is called a thrombotic stroke.


• A clot may break off from another place in the blood vessels of the brain, or from some other part of the body, and travel up to the brain. This is called cerebral embolism, or an embolic stroke.