comment on a comment…

Posted on Monday 22 June 2015

This comment on the last post [a requiem in the key of infrequent interaction…] might clarify some of my visceral aversion to the discussions of Collaborative and/or Integrative Care.

    I don’t think the APA leadership support of this is financially motivated. I think it is ideologically motivated. Which in this case is worse, because if they had the financial interests of the group in mind [not to mention basic professionalism and the interest of individual patients] they wouldn’t support it. Lieberman, who posted the first video about this from APA, was a big fan of carving out a role for psychiatry under ACA because he was thoroughly committed to ACA politically and the idea of treating populations rather than patients.
I’ve embedded two short APA videos on the topic: the one from Jeffrey Lieberman mentioned above and one from Paul Summergrad a year later. In addition, I’ve included more than you’ll want to look at from other APA sources:
APA: Collaborative Care

This is a population model that incorporates various instruments [screening, PHQ-9, etc] along the way. It’s built on the naive notion that one can treat mental health problems with a prescription pad and/or CBT. It reminds me of a graphic I drew when I first started blogging about psychiatry and mental health matters a number of years ago. I drew it meaning to be facetious, but maybe I should have applied for a patent…

    James O'Brien, M.D.
    June 22, 2015 | 7:42 PM

    I had a patient come in the other day and when we were talking about his depression I notice what appeared to be a pus pocket surrounded by cellulitis. The next day I called a friend who was an ID specialist and told him it was my impression that the patient had MRSA. My friend did not ask to examine the wound because insurance wouldn’t pay for that. He recommended an IV drip of vancomycin which I started the next time I saw the patient. Unfortunately the patient developed a clostridium infection and asked my friend about this again and he told me how to manage it. He never asked to see the patient since this was not permitted.

    Well of course this scenario never happened. This would all be reckless an irresponsible both by me and the ID specialist. And unimaginable. So we need to ask ourselves why in the hell is this acceptable when the shoe is on the other foot.

    June 22, 2015 | 10:59 PM

    Do they actually believe what they’re spouting?

    June 22, 2015 | 11:58 PM

    Dr. Lieberman’s intro is exactly the party line on managed care from the later 1980s. Substitute collaborative care for managed care. No leader of the APA should be using the terms “behavioral health” or “cost effectiveness”. Psychiatry is the current loss leader of all big tertiary care centers because we have been looking at cost effective in the rear view mirror for decades. You can’t get any more cost effective than being expected to provide care for free.

    The “unique model of care” is more successful managed care rhetoric. He seeks to differentiate managed care and rationing from collaborative care. The “cost saving” mantra is repeated.

    We need a leader who can stand up and say that we know what good care is and it is time to get it to everybody. Nobody has a problems with any middle-aged person getting admitted overnight for a $30,000 evaluation fro chest pain. Anyone with a first psychotic episode is as important and we can be as “cost effective” as Cardiology. But until we get to that point, our patients are not getting enough resources.

    June 23, 2015 | 7:59 AM

    “Do they actually believe what they’re spouting?”

    or practice it? or send their family for it?

    June 23, 2015 | 12:22 PM

    While this below comment was not from one of my appreciated supervisory staff during my residency, this psychiatrist did say one accurate and applicable thing to me: “everyone thinks they are a psychiatrist until the s*** hits the fan, and then who is out the door first, but these charlatans, and leaving just the patient and psychiatrist to take the hit”.

    And isn’t that what is going on, whether it be PCPs, FPs, NPs, OBGYNs, legitimate prescribing psychologists, and anyone else not a psychiatrist with a prescription pad, they think they know how to prescribe psychotropics, and then when they f— it up, gee, enjoy those dumps, colleagues!?

    I like Dr O’s above scenario, yeah, the one time one of us would be stupid to write for an antibiotic, and then send the patient to a somatic colleague, you think we would ever hear the end of those harassing comments from such colleagues for writing for antibiotics without culturing and initial interventions?

    I once got an angry, insulting call from a PCP for giving a patient a script for a hypertensive med the patient had been on previously with an impact and insisted the patient see the PCP for follow up thereon. Who are these losers who forget we are MDs and are actually doing the right thing, at worst starting a med and not agreeing to follow up without the expertise?!

    And you colleagues out there taking on these benzo patients from idiotic, irresponsible non psychiatrists, what are you doing to stop it?? Oh, and I am hearing some ERs in Maryland are giving out stimulants to patients of late???

    Am I the only one who remembers the adage “guilty by association”?

    and the silence is often deafening…

    James O'Brien, M.D.
    June 23, 2015 | 11:02 PM


    I think in their minds they do. One of the problems of academia is that great sounding theories get more attention than something that works in the real world.

    Supporting a concept that you think sounds good while on tenure means you get to be morally vain at university cocktail parties and at the May Water Buffalo Lodge meeting without ever having to deal with the real world consequences.

    BTW, the fact that most psychiatrists supported ACA but refused to take money from CMS or all forms of insurance is not a good reflection on their intellectual honesty or character. I can admire someone who supported it and sees Medicare patients, and I can respect someone who takes cash only but opposed ACA. Everyone else is a hypocrite not carrying their weight.

    James O'Brien, M.D.
    June 24, 2015 | 1:07 PM

    APA was completely on board with ACA:

    Notice that he is really totes happy about “parity”. But how is it parity if I can see a specialist face to face for any other medical problem but not a psychiatrist?

    This is nothing but an attempt to ideological will-to power. Rhetoric over reality. Wordsmithing does not solve the actual problem. As Lincoln would say you could call the tail of a dog the fifth leg but in reality the animal has four legs.

    And again, there is nothing to celebrate here since most psychiatrists don’t take insurance anyway.

    Billing Medicare for psych outpatient followup is such a hassle that its simply easier to see a few patients pro bono than to bother sending in claims.

Sorry, the comment form is closed at this time.