{"id":45986,"date":"2014-05-02T14:50:36","date_gmt":"2014-05-02T18:50:36","guid":{"rendered":"http:\/\/1boringoldman.com\/?p=45986"},"modified":"2014-05-02T15:01:14","modified_gmt":"2014-05-02T19:01:14","slug":"not-directly-seeing-the-patients","status":"publish","type":"post","link":"https:\/\/1boringoldman.com\/index.php\/2014\/05\/02\/not-directly-seeing-the-patients\/","title":{"rendered":"not directly seeing the patients…<\/em>"},"content":{"rendered":"
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Health Reform, Research Pave Way for Collaborative Care for Mental Illness<\/a><\/div>\n
by Bridget M. Kuehn MSJ<\/div>\n
JAMA<\/font><\/strong>, June 19, 2013 309[23]:2425-2426.<\/div>\n

<\/p>\n

JAMA<\/font><\/strong>: What is collaborative care?<\/em><\/div>\n
Dr. Katon<\/font><\/strong>: It involves a care manager, who is a nurse or other collaborative care professional, who sees the patients and provides enhanced education and tracks their outcomes. The care manager uses a case registry to monitor all the patients being treated for mental illness in the practice. If a practice physician starts a patient on an antidepressant, the care manager monitors the patient’s response. The care manager’s job is to make sure patients don’t fall through the cracks. The care manager receives weekly supervision from a psychiatrist, who, based on the patient’s experience with the medication and initial clinical response, may recommend medication changes. The care manager communicates the psychiatrist’s recommendation to the primary physician.<\/em><\/div>\n

<\/p>\n

JAMA:<\/font><\/strong> What kind of training do clinicians need to implement this model?<\/em><\/div>\n
Dr. Katon<\/font><\/strong>: It’s a new role for psychiatrists because they are not directly seeing the patients.<\/font><\/strong> Most psychiatrists are used to working directly with the patient vs being responsible for a population of patients. It’s a team approach.They must learn the concepts of measuring care outcomes and utilizing stepped-care approaches where increases in intensity of care are driven by outcomes. The American Psychiatric Association offered a course in collaborative care at its annual meeting. The Academy of Psychosomatic Medicine also has training in this model of care.<\/em><\/div>\n<\/blockquote>\n
This article I’ve been quoting is actually an interview of Psychiatrist Wayne Katon, MD, Professor of psychiatry at the University of Washington in Seattle, who has worked to "develop and test models for integrating mental health care into primary care practice for the past 30 years." While my comments are critical, I mean him no malice. It sounds as if he’s trying to be helpful by improving the quality of psychiatric care being delivered by primary care physicians. Good for him. As I said in my last post, they sure need the help.<\/div>\n

When I read the criticisms of psychiatrists in the comments on this and other blogs, the psychiatrists being raled about were unfamiliar to me. They are people who see patients for brief sessions and prescribe medications based on symptoms. At first, I thought the critics were exaggerating, but that’s not right. They are seeing psychiatrists shaped by the APA\/DSM-III\/Academic\/PHARMA\/Managed-Care view of psychiatry. Psychiatrists willing to sign on to their panels. And their complaints ["bio-bio-bio"] are perfectly legitimate. It’s the psychiatry third party payers have been willing to pay for ["medication management"]. If referred for any kind of therapy, it would be to other mental health types who have agreed to be on "the plan." That split arose with the arrival of Managed Care. The Carriers paid psychiatrists well to do "medication management" only and opened up insurance reimbursement to non physicians because they charged less and would agree to the kind of control the carriers were interested in. So the psychiatrist\/therapist split became the standard for the last twenty plus years.<\/p>\n

Certainly by the time I went into practice [late 1980s], that writing was on the wall. I thought about returning to Internal Medicine, but that’s not where my heart was. So I opened my office and worked hard for twenty years. I decided that insurance wasn’t any of my business, so I gave out bills with a DSM Code and a CPT code and left the rest to my patients, refusing requests to call for approval or join anything. I was blessed with a decent reputation from my academic years and a wife who, like me. came from a modest background and aspired to nothing more than that. So I worked long hours, adjusted fees for people that I thought I could help and couldn’t afford treatment, and was way busier than I needed to be.<\/p>\n

I refer to those years as being in a cocoon<\/em> or cloistered<\/em>, because I didn’t know how much things were changing. But at the time, it didn’t feel that way. My close associates were doing the same thing and it just felt like my life. The point here is that the psychiatrists being criticized made a lot more money than I ever did, and they did what they were being paid to do. They are now what people see in their minds when they say "psychiatrist." There was a flowering of psychologists, social workers, etc. in private practice being paid by the Managed Care people to do time limited therapy\/counseling and glad for the work. Since I wasn’t on any plans or panels, I never saw people whose carriers controlled things so tightly. My patients who used insurance did their own dealings with their carriers.<\/p>\n

My intuition is that that this system is going to come to something of an end. This Integrative Care business sounds like a move to reduce or eliminate the involvement of both the psychiatrists and the therapists. Notice that the only mention of therapy is, "May offer brief psychotherapy<\/em>" for the "care managers" [two versions…<\/a>]. So essentially "covered" mental health care means medication from primary care followed along using tests like the PHQ-9.<\/p>\n

Managed Care has no interest in covering mental illness and never has – cutting reimbursement wherever possible. Having essentially created the psychiatrist everyone complains about as the standard, they are now moving to cut even that, as above. The psychiatrists are going to be reimbursed for reviewing charts with a care manager and that’s it. I expect they’d like to get non-physician mental health types to be "care managers."  Why the APA would be actually promoting such nonsense is beyond me. The Academic\/Pharmaceutical complex seems to be morphing into the Academic\/Managed Care complex quickly. <\/p>\n

The new criticism is that psychiatrists will be doing their "bio-bio-bio" thing without even seeing the patients at all. As you can surmise from the quotes above, about the only thing psychiatrists who agree to do this Integrative Care can do is talk about medications with a care manager with a list of medicated patients and a fist-full of test results. The end of this story is that decent mental health care isn’t going to be "covered" at all. In truth, it hasn’t been "covered" for a very long time. I’m glad I saw where all of this was headed such a long time ago and didn’t even think about entering that arena. That’s why so many of us aren’t in the AMA, or the APA, or on any of the Managed Care panels. <\/p>\n

Personally, what’s happening here bothers me a lot, just as it did thirty years ago [and in-between], but I have no idea where it’s headed or what to do about it. This blog isn’t about that. It’s about insuring that the science part is legit, and it hasn’t been…<\/div>\n","protected":false},"excerpt":{"rendered":"

Health Reform, Research Pave Way for Collaborative Care for Mental Illness by Bridget M. Kuehn MSJ JAMA, June 19, 2013 309[23]:2425-2426. JAMA: What is collaborative care? Dr. Katon: It involves a care manager, who is a nurse or other collaborative care professional, who sees the patients and provides enhanced education and tracks their outcomes. The […]<\/p>\n","protected":false},"author":2,"featured_media":0,"comment_status":"open","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"_bbp_topic_count":0,"_bbp_reply_count":0,"_bbp_total_topic_count":0,"_bbp_total_reply_count":0,"_bbp_voice_count":0,"_bbp_anonymous_reply_count":0,"_bbp_topic_count_hidden":0,"_bbp_reply_count_hidden":0,"_bbp_forum_subforum_count":0,"footnotes":""},"categories":[2],"tags":[],"class_list":["post-45986","post","type-post","status-publish","format-standard","hentry","category-politics"],"_links":{"self":[{"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/posts\/45986","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/users\/2"}],"replies":[{"embeddable":true,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/comments?post=45986"}],"version-history":[{"count":19,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/posts\/45986\/revisions"}],"predecessor-version":[{"id":46005,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/posts\/45986\/revisions\/46005"}],"wp:attachment":[{"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/media?parent=45986"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/categories?post=45986"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/tags?post=45986"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}