Sunday, April 06, 2014

Dear Congressman Murphy: Regarding HR 3717

American Enterprise Institute, AEI, a conservative think tank, held a panel on Fixing The Mental Health System, What Congress Can Do.  I posted the discussion above, the talking begins at 12 minutes.  The panel is introduced by Dr. Sally Satel, and the speakers include:

  • Congressman/Psychologist Tim Murphy who talks about legislation in Congress, HR 3717.  This bill pushes the federal government to provide more services -- a good thing -- and it also ties in requirements for Involuntary Outpatient Treatment (also known as Assisted Outpatient Treatment or AOT).  The New York Times has discussed this in Mental Health Groups Split on Bill To Overhaul Care.  
  • Dr. Jeffrey Lieberman, the President of the American Psychiatric Society
  • Dr. E. Fuller Torrey of the Treatment Advocacy Center
  • Former Congressman Patrick J. Kennedy
If you'd like to watch the event, the video is above, if you want to read about it, read Here. 

I don't want to dwell on the issue of involuntary treatments today, but instead, I'd like to make some comments on H.R. 3717 The Helping Families in Mental Health Crisis Act.  I've read about the bill, I have not read the full text, but if you'd like to, it's here. 

Dear Congressman Murphy,

I'm no fan of HIPAA, as a physician, I find it makes it more difficult to get information from other clinicians.  Your point, however, that HIPAA prevents a doctor from getting information from a family is not quite right and you were more on target when you said it was misunderstood.  Physicians can listen, and families can talk, but privacy laws mean that physicians can't release information without the patient's permission.  Actually HIPAA defines all sorts of entities that can get medical information, but there is nothing in it that says a family member can't tell a physician about their concerns or relay past history.  Sometimes, clinicians refuse to release information to families or even other physicians, citing HIPAA, when in fact, they haven't specifically asked the patient for permission.  Sometimes doctors or facilities are lazy, sometimes they are misinformed, and sometimes they are afraid of being sanctioned or sued so they err on the side of being overly careful about whom they communicate with.  For the most part, I don't believe that doctors should release psychiatric information unless a patient consents to this.  Lets hope that everyone's judgement on these issues gets a lot better. 

In talking about access to care and a shortage of psychiatrists, because psychiatrists are in such demand, many psychiatrists have chosen to opt out of participating with health insurance.  I've written about that Here.  Part of the access problem lies with the fact that insurance companies either restrict patients to seeing in-network psychiatrists, or reimburse less if patients go out of network.  At the same time, insurance companies will list psychiatrists as being in their network when they are not, creating the false impression that the network has plenty of providers: see this Wall Street Journal Article.   So what about increasing the number of available psychiatrists by requiring insurance companies to reimburse the same for both in-network and out-of-network treatment when access to care becomes difficult?  If a family is told that the next in-network appointment is 6 weeks away, but an out-of-network doctor can see them the next day, should the insurance company really be permitted to save money and reimburse less?  And should insurance companies be permitted to have "Usual and Customary" rates that are far below the community standard?  And perhaps if Medicaid and Medicare would reimburse for out-of-network services (they don't), the number of treatment options might open up. 

Finally, you talked a lot about the standard of "imminent danger" as being too high standard for hospitalization.  That's all well and good, and I agree with you that we shouldn't be waiting for metastatic disease (as your comparison mentioned) to begin care, on an inpatient unit if needed.  But it's not just about that standard of care for forcing treatment, it's about what insurance will reimburse for.  Have you ever tried to admit a patient to a hospital?  Insurance companies generally will not authorize treatment for psychosis alone.  The only level of illness that they will authorize inpatient care for is the same level that one needs for involuntary commitment: imminent dangerousness.  So you can drop the level of illness it takes to get a patient admitted -- and I presume you mean by allowing for involuntary treatment -- but does it matter if the law changes to a "need for treatment" standard if insurance companies don't agree that the patient needs treatment?  I asked a woman the other day why she didn't sign herself in voluntarily after a serious suicide attempt -- she was being transferred from an ICU and was distraught that she was being 5150'd (California lingo).  She told me the doctor said the insurance company wouldn't pay for the admission if she wasn't committed, otherwise she would have signed herself in.    One ER psychiatrist I know was asked by the insurance company if the patient's gun was loaded.  Does that matter?    If the Navy Yard shooter had been brought to the hospital by the police, as he should have been, they may well have let him go if it was believed that insurance wouldn't pay for an inpatient stay.  And while severely mentally ill people may have higher rates of violence, studies have shown that treatment deceases violence.  In fact, patients who are seen weekly after a hospitalization are half as likely to be violent as the general population -- voluntary treatment makes a big difference.  But getting that level of care for our patients in the public mental health system only happens with the few who get put with Assertive Community Treatment teams. 

One thing is clear, before we start forcing care, let's make sure there is even care to be had, and that those who want it, or can be encouraged to get it, have a means to do so.