{"id":46810,"date":"2014-06-02T14:08:17","date_gmt":"2014-06-02T18:08:17","guid":{"rendered":"http:\/\/1boringoldman.com\/?p=46810"},"modified":"2014-06-02T14:53:13","modified_gmt":"2014-06-02T18:53:13","slug":"insels-lament","status":"publish","type":"post","link":"https:\/\/1boringoldman.com\/index.php\/2014\/06\/02\/insels-lament\/","title":{"rendered":"insel’s lament…"},"content":{"rendered":"
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The Paradox of Parity<\/a><\/div>\n
Director’s Blog – NIMH<\/font><\/strong><\/div>\n
By Thomas Insel<\/div>\n
May 30, 2014<\/div>\n

… The paradox of parity is that even with the new laws, in the absence of such a framework, some treatments might not be covered even to the extent that they were covered in the past. To address this concern, NIMH and other stakeholders have asked the Institute of Medicine [IOM] to develop a framework by which standards for psychotherapeutics can be established to help guide both payers and providers. The IOM has set up an expert panel to review the issues and recommend a way forward. At a meeting last week, the IOM panel heard how other providers like surgeons have established guidelines for rigor and quality that ensured parity for their interventions, many of which have less evidence than what we have for cognitive behavioral therapy.<\/p>\n

In the world of parity, psychosocial treatments may need to be accompanied by measures of quality and fidelity [e.g., evidence of homework if the treatment is cognitive behavior therapy], measures of dose and duration [e.g., a predetermined length of intervention], and measures of outcome [e.g., improvements on a standardized rating scale]. And electronic records may become as essential to psychotherapy as the rest of medicine for ensuring that treatments meet established standards and are reimbursed.<\/font><\/strong><\/p>\n

Of course, many providers may look for reimbursement outside of the insurance or Medicaid systems. A recent report from Bishop et al found that only 43 percent of psychiatrists accepted Medicaid and only 55 percent accepted private non-capitated insurance. These figures are much lower than rates for other medical specialties [73 percent for Medicaid and 89 percent for private insurance]. And the rates for psychiatrists accepting private insurance are going down, decreasing 17 percent from 2005–2006 to 2009-2010 when these data were collected.<\/p>\n

It would be a sad irony if in the era of parity only those who could afford to pay out of pocket could get access to effective psychosocial treatments. The IOM study can help by providing some guidelines, but true parity may require that the mental health community take steps to demonstrate that they provide the most evidence-based treatments with measures of both rigor and fidelity. We will need standardized reporting systems. And we will need a detailed definition for each evidence-based intervention, including not only dose and duration but indication…<\/div>\n<\/blockquote>\n
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Dr. Insel<\/a> left his Psychiatry Residency for the NIMH in 1980, moving to Atlanta to direct first the Yerkes Primate Center in 1994,  then a National Science Foundation Science and Technology Center in 1999, and returning as director of the NIMH in 2002 to the present. He is said to announce that he has never done clinical psychiatry, something I would’ve pointed out for him had he not done so himself. Not mentioned in Dr. Insel’s blog or in the article by Bishop et al<\/a>, is that the insurance-accepting psychiatrists represented in their tally are not those offering psychosocial interventions, but primarily the psychiatrists prescribing medications [Clinical Neuroscientists<\/a>] – willing to accept the reimbursement schedules of the Insurance\/Medicare\/Medicaid systems [which, by definition equates to med-checks<\/em>].<\/div>\n

I don’t even know where to start. And since I didn’t want to rant, I took a break and made coffee [it seemed to have helped]. They created a reimbursement system that essentially directed psychiatrists to do pharmacotherapy, and backed it up with an academy obsessed with Clinical Neuroscience, a disease-model Diagnostic System, psychopharmacology, and a not-so-subterranean alliance with the pharmaceutical industry. Insel mentions CBT [Cognitive Behavior Therapy] as his example of an evidence-based psychosocial intervention because it and its variants are essentially the only ones that have earned the EBM moniker. I was certainly influenced by the principles of CBT, incorporating them into my everyday approach to people, but I’ve never personally been or worked with a psychiatrist who does formal time-limited CBT with homework for very long beyond training – though it’s listed on most r\u00e9sum\u00e9s. And if there were or will be such psychiatrists, they will need either lots of free time or an expensive support staff to manage the system described in the highlighted paragraph above [to handle the paperwork\/electronic records involved]. Being independently wealthy would also be an adjunct. <\/p>\n

I see nothing in this vision of mental health parity that will change the practice of psychiatry represented even by the insurance-accepting psychiatrists in those graphs, or do anything to halt their dwindling numbers. I see nothing in this vision of mental health parity that reflects anything but Dr. Insel’s disconnect with the specialty of psychiatry and its practice. He and his colleagues in academic psychiatry and the American Psychiatric Association created a vision of the future that lead us to where we are now based on an as-yet-undiscovered neuroscience<\/em> with a reliance on some not-so-very-effective drugs<\/em> based on a not-so-very-helpful diagnostic system<\/em> and a not-so-very-enduring-or-healthy relationship with industry<\/em>. Their hope for a breakthrough neuroscience pharmacologic future has now tanked, and they’re scrambling to find some new directions with things like collaborative care and whatever-you-call-the-thinking<\/em> in this post. Were I to allow my suppressed rant unrestricted access, I would speak heatedly about the role the non-practicing psychiatrists like Dr. Insel and his cronies in academia and organized psychiatry had in creating this un-holy-hell-of-a-mess<\/em>, and their unwillingness to accept responsibility for the impact of their short-sightedness-and-monocular-ideology<\/em> on the fate of both psychiatrists and our patients.<\/p>\n

The central complaints about psychiatry are that psychiatrists don’t seem to want to talk with and listen to their patients anymore, and that they treat everything with medication. Those complaints are primarily generated about the psychiatrists under the curves in those graphs – referred to as "in-my-network,<\/em>" "on-my-plan,<\/em>" or just plain "covered<\/em>." And I don’t say that to malign them. Many of them are doing the best they can and I hope that somehow the mental health parity act will ultimately expand their availability and the range of services they can realistically offer their patients. But I’m skeptical that the reflections of Dr. Insel in this post [or his IOM Committee] are going to do much to further that goal… <\/div>\n","protected":false},"excerpt":{"rendered":"

The Paradox of Parity Director’s Blog – NIMH By Thomas Insel May 30, 2014 … The paradox of parity is that even with the new laws, in the absence of such a framework, some treatments might not be covered even to the extent that they were covered in the past. To address this concern, NIMH […]<\/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-46810","post","type-post","status-publish","format-standard","hentry","category-politics"],"_links":{"self":[{"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/posts\/46810","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=46810"}],"version-history":[{"count":27,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/posts\/46810\/revisions"}],"predecessor-version":[{"id":46837,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/posts\/46810\/revisions\/46837"}],"wp:attachment":[{"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/media?parent=46810"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/categories?post=46810"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/tags?post=46810"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}