Saturday, October 06, 2012

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 psychiatrists 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 psychiatrist 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.


Anonymous said...

"Some of the questions that have come up in our comments section imply that there are precise answers to these questions."

I don't agree. I think people are implying the opposite and bringing in different points of view - isn't debate the point of this blog? We might not agree what "best" looks like, but do we disagree that the current US system is not "best"? There are no solutions, we just have to decide which dilemmas we can live with.

George Dawson, MD, DFAPA said...

"Do capitated systems (coverage for all with a single pot of moo-la) make it harder to get services?"

Anyone who thinks that they are getting quality care from a capitated system is not very knowledgeable about how the health care system works. Not only is quality of care affected - the availability of services is also affected and the entire practice landscape is negatively affected. When you speak of psychiatrists seeing 4 patients per hour for anywhere from 5-10 minutes - the object is not to make more money - it is to fight the effects of a capitated system that is barely paying enough to keep a practice open.

Consider this comparison - a middle aged man going to the emergency department. In one case he has chest paint and the differential diagnosis is cardiac versus esophageal pain. In the other case he is in alcohol withdrawal. Both are potentially life threatening conditions. In the first case he will get admitted and get a $15-20,000 workup - even if it is only a day or two. In the case of alcohol withdrawal, the ED will check with local non-medical detox units (moved off site by managed care policies) and if they don't have a bed - he could be sent home and told either to keep drinking or given a bottle of benzodiazepines to detoxify himself.

Managed care and capitation clearly reduces the availability of services and the quality of service.

The solution has always been to fight the politics behind managed care and there is nobody willing to do it. It is a license to make money for providing high volume and low quality service. It is also a license to treat professionals like they are production workers and ignore their professional standards for individualized care.

Anonymous said...

Is it that a capitated system per se cannot work, or that existing capitated systems that don't work? Give organisations a bunch of money, with the incentive that that they can keep as profit anything they don't spend, you betcha they're going to provide a crap service if there is no oversight. On the other hand, we cannot have everything we want, we cannot afford it. We cannot make decisions based purely on individual care, we have to think of the overall health and well-being of the nation.

Anonymous said...

i know one thing, i would much rather have a cardiac problem in the U.S. than England. i have a friend who has been a nurse in both countries and she said you definitely get what you pay for and in England nurses don't have near the skills.

She worked in a CCU here in the U.S. and went back to visit a relative in a hospital in England and noticed that the patient in the bed next to her relative's had converted to a rhythm that you don't want to convert to. The nurses there didn't do anything because they weren't expected to know to do anything about it - that was the doctor's domain. So, she ran and found a physician herself and he was shocked that she understood what was going on. She said one of her nursing duties in England was to make tea for the doctors (i thought she was joking - she wasn't) and that it was much more of a caretaking role rather than a skilled nursing role. She came to the U.S. because nursing pays a lot more here and she likes that nurses are taught more and expected to know more here. She also had plenty of negative things to say about the U.S. healthcare system but does prefer it here.

George Dawson, MD, DFAPA said...

"Is it that a capitated system per se cannot work, or that existing capitated systems that don't work?"

It depends on who they are working for. They work well for insurance companies, managed care companies, and pharmacy benefit managers. They can make large margins based on these procedures. They work poorly for patients and physicians.

Current mental health systems are a model for how capitation and managed care can decimate a particular service area. You will always find exceptions, but there is widespread consensus among psychiatrists that inpatient services are essentially worthless for addressing complex problems and the only jobs out there within organizations are for an endless schedule of 15 minute "med checks". Access to psychological testing testing and long term therapy in many systems has essentially been eliminated.

As usual there are some exceptions, but even in the most straightforward medication change as discussion of the potential risk/benefit can easily take up the available time.

Is it acceptable to tell somebody to make another 15 minute appointment or tell it to their therapist at that time? Not from where I stand, but I have heard that same line from doctors I am seeing.

Managed care quite literally has an adverse effect on professionalism by rationing in order to maximize profit for the companies. The conflicts of interest that psychiatrists are accused of in the media are trivial by comparison.

Anonymous said...

Well, in my mind that's a good argument for nationalising health care so that it is answerable to the people - we all need to be stakeholders.

I don't know about the quality of cardiac care in the UK, but at least everyone in places like France, the UK, and the Scandinavian countries have access to basic healthcare that many Americans do not.

Anonymous said...

I find it baffling that once again you have taken an issue that you began that centered around your and/or other psychiatric professionals practice and changed it so that you no longer hold even a pretense of responsibility. It's the system's fault, it's the patient's fault, it's insurance's fault, but certainly not yours. You may be in the wrong profession....but unfortunately, you are quite prototypical of it.

Anonymous said...

Am I the only one who finds all the anonymouses (anonymi?) confusing? I'm not sure who the last poster is baffled by?

It is a dilemma for me - I don't want to use my real name and I don't have an online persona, but I would like people to know which posts are mine. I suppose if I sign myself "anonymouse" that would be just too dorky!

Jane said...

I actually find Medicaid to be weird. A lot of docs won't accept it, because it is so substandard and terrible. But a lot of disabled people are on I would think the incentive would be to get these people the best care possible so they can go back to work by getting them as healthy as possible. I feel like the country actually loses money by giving such terrible care to disabled people.

I do understand why people are freaked out by national healthcare...because they are afraid it will look like Medicaid.

Anonymous said...

Jane, you are exactly right. Look how many psychiatrists here take medicaid.

Sheila said...


Let me start by saying how much I enjoyed reading the debate on this blog in the last couple of days. This is luxurious - I understand how important this health-economics topic is, but it is luxurious in the sense that healthcare professionals do have time discussing these, instead of rushing through their clinical duty, or having a much-treasured day off and decide to spend it on the country-side after having a hectic week seeing 25-30 known patients + 1 new patient per 4 hour outpatient session.

This is my life, at least.

This brings me onto the debate between fee-for-service and capitated service. There are two domains in my mind:
1. In terms of how much of the population were covered by the service
2. In terms of the "service quality" each person receives

In terms of how much of the population were covered by the service, there is no doubt that capitated services covered all. In terms of quality, as rich / middle class people are also users of capitated services, the society (i.e. tax payers) had a certain level of expectation to their healthcare quality. Public pressures were effective enough to make the health system deliver what they should. I would say, in the public health system in Hong Kong, we can compare ourselves to most developed major cities in the world and say our care are no less adequate.
However, one obvious down side about the capitated system in Hong Kong is that our staffs are heavily overloaded. Because of public pressure, we cannot cut down investigation or treatment costs. We cannot deny assess to more costly treatments. We were required to follow international guidelines. Essentially nothing "medically required" were cut down.
But the "environment" that you receive these services were no good. Staff are heavily overloaded - they will deliver proper care because they will be penalized if they don't, but don't expect them to be very polite. Expect 2 hours waiting time in the outpatient clinic before you get to see your doctor. Expect another 2 hours waiting time before you can get your drug from the hospital pharmacy. However, you do get your abilify (no matter how expensive it is) if that's what you need.

I don't grew up in a fee-for-service system. I have relatives and friends in the US though, and I have visited hospitals in the states. I really appreciated the environmental quality that was offered - patients were treated in a very humane manner. There is no doubt that they are managed in the most proper and comprehensive way professionally. Staff were not overloaded, they greet you with a smile and explain to you with patience.
But what if you are not insured, only relying on medicaid? It comes back to my first point: "how much of the population is covered by adequate service". I do worry that if I am not one of the insured, I will be receiving haloperidol instead of aripiprazole. I may not be able to have a Chest XR even if I have coughed for a month. I am not only worried about the "environmental quality", instead I am worried about the quality of my professional medical care.

There are pros and cons for everything. If I am one of the poorest, I will say thanks to my Government for covering me in a capitated service, though I am staying in a very crowded ward and nurses never smile at me. If I am one of the richer, I will prefer fee-for-service looking for medical AND ENVIRONMENTAL quality.

I will end by stressing the importance of providing "choices". Either system had it's down side. What my city does, is that it has a mix of public / private healthcare. It has it's own problem though, but people were free to choose whether they wanted to be treated in the public or private system.

Anonymous said...

Sheila - That is talking in terms of outpatient services, or else just an absurdly rose-covered-glasses perspective. In an emergency, you go to the same closest ER as the medicaid patients. Even with private, excellent insurance, when I had to go to the ER (for surgical even, not psych reasons), I went to the best ER in the city and one of the best ranked in the nation -- and receieved the same irritated, rushed, harried, unfriendly, non-smiling service as did the medicaid patients. You are sadly mistaken when you think that private insurance gets you anything better. It just means that I had to pay for a portion of my harried, rough, rushed treatment, while a medicaid patient with the exact same surgical issue gets it for free, with the same excellent treaters.

It's always greener on the other side....

Anonymous said...

I agree with the commenter above. Insured or not my experience is that we got the same treatment as those patients with more means. Before the legislation which prohibited insurance companies from denying people based on pre-existing conditions my sister was born with a congenital heart defect and got denied by insurance, so 3 open heart surgeries ended up being covered by charity care - we made too much to qualify for medicaid.

I'm sure other countries might like to hear that she died without any care, and we all became homeless and living in the streets, but that wasn't the case at all. She received the same exact care that a rich child would have received. She was not in an overcrowded hospital, and she had her own hospital room once she was out of icu. Certainly, our system can use some work, but it's not all horror stories if you're uninsured - incidentally, when she had pneumonia she didnt cough for a month without a chest xray, she received a CXR immediately along with hospital care and iv antibiotics just as any other patient. i know this doesn't fit the tragic paradigm some would like to believe, but that was our experience.

it does seem like in other countries that psychiatrists are more willing to be paid less to ensure that all patients receive care. Not sure they would be willing to do that here. I suspect it would remain a 2 tiered system like it is now.

Eliza said...

"I'm sure other countries might like to hear that she died without any care, and we all became homeless and living in the streets... "

What an unkind projection to make. I'm curious why you think that anyone would want to hear that someone has suffered presumably because it justifies their political views. I'm very glad to hear that a charity stepped in and your sister received the care you needed and your family was supported. Surely, however you know that many many people in the US have suffered due to poor access to even primary and preventative medical care.