Thursday, January 27, 2011

The Devil Inside: Access to Mental Health Care in the United States

This is third and final posting in a series on the shooting of 13 people in Tucson and its implications for health and social policy in the US. This post is by Robyn R. Liu, MD, who is a family physician in the frontier town of Tribune, KS, in the far western part of the state.

The day Gabrielle Giffords and 19 others were shot is one of those days that most Americans will remember where they were when they heard the news. What I will remember is my husband saying, “A congresswoman was shot in Arizona. She was on Sarah Palin’s crosshairs map.” As our picture of the alleged shooter became more complete, we realized he was not playing John Hinckley, Jr. to Palin’s Jodie Foster. Rather, he is in all likelihood a very disturbed, mentally ill young man.

A CNN/Opinion Research poll demonstrates that most of the public agrees, and thinks that the lack of mental health resources was in part responsible for the horrific act of that day: 41% said a “great deal,” and 29% said a “moderate amount.” When NPR went to a gun show held in Tucson just seven days after the shooting, the man at the front of the line said, “Mentally ill individual, very troubled individual that unfortunately slipped through the cracks somehow. And I think that’s what we need to look at, is how did this fellow get missed.”

As a primary care doctor in a frontier state, I can tell you, those cracks are pretty big.

I wrote a piece last week for another blog about one patient’s experience with the mental health system here in Kansas. This was a patient with insurance and a continuity relationship with a psychiatrist – and even she “fell through the cracks” more than once, although her violence was all self-directed and thus never made headlines. We do not know what Jared Lee Loughner’s health insurance status was, nor whether he had ever sought a therapeutic relationship with a mental health professional. We do know that although his behavior got him rejected from both college and the military, he was able legally to purchase a handgun and a 30-round magazine. As Dr. Dora Wang noted this week in Psychology Today, “It’s easier to get a gun than mental health care.”

I decided to do some looking into mental health services in Arizona. I went to the home page of the Arizona Medicaid program, forthrightly if a bit unfeelingly called the “Arizona Health Care Cost Containment System,” or AHCCCS. I already knew that AHCCCS was looking at cuts in Governor Jan Brewer’s new budget, since by her direction 98 people had had their transplants rescinded under this program. The Division of Behavioral Health Services website describes how the governor’s proposed 2011 budget would alter Medicaid eligibility criteria for “childless adults” like Loughner, possibly removing coverage for 5,200 Arizona citizens with “serious mental illnesses.” The writer hopes, however, that a loophole in the policy will allow “more than 80% of these folks” to maintain coverage under a different Medicaid category. Oh, thank goodness! Now only 1,040 seriously mentally ill people will suddenly find themselves high and dry in Arizona.

The longer we as a society refuse to provide universal health care, with complete parity for mental health, the wider these cracks are going to get. It wasn’t an illegal immigrant who shot down a federal judge, a pastor, two homemakers, a social worker, and a little girl in cold blood. A retired Marine is not lying in the hospital with bullet wounds he suffered trying to protect his now-dead wife because of a drug-smuggling Mexican. Arizona is worried about protecting its borders, but its greatest threat may already be inside. Imagine over 1,000 Loughners walking the streets with no means to get help: it’s absolutely chilling.


Postscript from Josh:

In the January 27, 2011 NY Times, columnist Gail Collins quotes Senator Tom Coburn of Oklahoma from an appearance on "Meet the Press":
“The people that are going to commit a crime or are going to do something crazy aren’t going to pay attention to the laws in the first place. Let’s fix the real problem. Here’s a mentally deranged person who had access to a gun that should not have had access to a gun.”
As Senator Coburn is a physician, he should know. And, hopefully, he will sponsor legislation to create some rational limits on gun access, as well as increasing access to mental health services. But I wouldn't hold my breath.

Friday, January 21, 2011

Tucson is worth struggling for...

This guest post by William Bemis is the second of three related to the recent shootings of Gabrielle Giffords and others in Tucson (in Pima County), AZ. Shortly before the shootings, the NY Times reported on a decision by the AZ Board of Education (a state agency in the capital, Phoenix) to close a Latino studies class in a Tucson High School. Urged by family members to consider relocation, Mr. Bemis, a psychotherapist and my brother-in-law, wrote this response, speaking of the Arizona city whose City Council had previously voted to ask the state to rescind its anti-immigrant law; after the shooting, at my request, he added additional material.

No, my dear, it's time for us and others like us to re-double our efforts to not only preserve Pima County as an island of sanity in this sea of ideological madness, but help the rest of the state and the nation see that leaving all the levers of power in the hands of racist corporate stooges is not going to take us anywhere but down. Having lived in this state for over 40 years now, I've seen this before - with Evan Meacham and Fife Symington, for example. After each of these lunatic lurches to the right, the state came back to at least a more moderate centrist political configuration. Arizona will never be Massachusetts or Oregon or Minnesota, but I, for one, am not ready to leave and concede this beautiful and unique place to the hate mongering front men for big money interests.

I loved living in New York, but we could never afford it, and besides, although their antics are less spectacularly loony, I wouldn't call the New York state government an example to emulate. Where else? Illinois? Puh-leeze! California? Are we talking about the homeland of Nixon, Reagan, Robert Dornan, et al? Sadly, Californios have also had to deal with home grown right wing fanatics, que no? Oregon? A more congenial political environment, perhaps, and a beautiful state, but too much rain!

It isn't just here, is it? I think we have to take the long view. The so-called conservatives (what do they wish to conserve besides entrenched wealth?) are riding high right now, both here and in Washington, but in the next couple of years they are going to amply demonstrate the meaness and poverty of their ideas. Contrary to the self delusions of Russell Pearce, Jan Brewer, Mitch McConnell, and John Boehner, I think these folks are cruising for a fall. I am more worried about the failure of those of us who do not share their agenda to take advantage of this moment than I am of the pseudo-populist, big money financed Tea Party. They have the money, so we all have to write our more modest checks and work all the harder. Our own apathy and discouragement is the enemy.

Moments after writing the above, I heard the news that Gabrielle Giffords, our Congresswoman, had been shot by yet another disturbed young loner of the type who seem to implement "Second Amendment solutions " to their private frustration and alienation on an almost daily basis now, thereby spreading their own psychic pain to all the rest of us. Cue the required messages of horrified shock and condolences from politicians of all persuasions, including even Sarah Palin who put Gabby's district literally in the rifle sight cross hairs and who tells her followers, "Don't retreat, RELOAD!" Some of those messages are no doubt sincere, but the one politician who was the most eloquent to me was Pima County Sheriff Clarence Dupnik, who doesn't get nearly the amount of press as his counterpart in Maricopa County, possibly because he is a hardworking, low key, decent, and fair public servant, which never seems to make good copy. Sheriff Dupnik's comments about political vitriol triggering mentally unbalanced individuals goes right to the heart of the current political climate in Arizona and across the country.

Gabrielle Giffords is a self-described "Blue Dog Democrat". For me, her politics are way too centrist in an era when what used to be the core values of the Democratic Party are under siege. If only she fit the liberal label that the Tea Party would like to pin on her! Though Gabby's stances on a lot of issues frustrated me, I worked as a volunteer on her election campaigns because I knew she was absolutely the best person we could hope to have elected to Congress from her district, which is Republican overall and in many precincts virulently racist and violent. Gabby is smart, dedicated, articulate, hard-working, extremely personable, and so much better than her recent opponent whom she barely defeated that I would have been ashamed if he had won and I hadn't done what I could to put her back in office. She is surviving so far the bullet that passed through her brain, and the trauma surgeons are optimistic, but I can't help but wonder if she does survive if she will ever be able to function again at the level she did prior. I read somewhere that she was advised recently that she had been too inaccessible in the past, though I seem to remember hearing frequently over her four years in office about her holding meetings for constituents to communicate with her. I wonder now if our congresspeople, like so many others in the public eye will have to be so security conscious that normal interaction and give and take between them and their constituents will be impossible. Yet another weakening of democratic process in this country.

Some of the murdered in this incident include a nine year old girl who wanted to learn more about politics and government, a well-respected federal judge, Gabby's constituent services director, and three civic minded elderly retirees.

We couldn't afford to lose any of them, either. But, we mustn't think that the easy availability of guns had anything to do with this tragedy. "A well regulated militia, being necessary to the security of a free state, the right of the people to keep and bear Arms shall not be infringed." I suppose it would only show my hopelessly liberal anti-freedom bias to suggest that a little more regulation of our vast militia of arms bearing people might be in order.

Saturday, January 15, 2011

Risk, Primitive Reactions, and Human Health Behaviors

NPR’s “All Things Considered” recently reviewed several scary events from 2010 (“The year in fear: fright or fallacy?”). Reporter Jon Hamilton spoke with Dr. David Ropiek, Director of Risk Communication at the Harvard Center for Risk, about what made these events (Toyota’s acceleration problems, the Deepwater Horizon oil spill and the use of chemical dispersants, etc.) particularly frightening. Dr. Ropiek said that people tend to make decisions, and react positively or negatively, based on very simplistic (and usually unconscious) criteria, rather than on careful critical analysis of the relative benefits of one course of action over another, with the most important criterion being “is there immediate danger?” The reason he gave was that our basic neurobiology was unchanged over human history while our culture and society was remarkably more complex than when quick decisions were mostly about achieving immediate results (fight or flee). “We use a risk-perception system that evolved in simpler times, when the risks were bad guys with clubs, and the dark, and wolves. It's quick. But quick isn't necessarily the best for the complicated stuff we face in modern society.” Thus, for example, even though the evidence would show that the human and environmental danger of the oil spill was in the oil much more than any risk from chemical dispersants, “Just the word chemicals in your listeners' minds is currently setting off a little organ in their brain called the amygdala, which is the 24/7 radar in our brain that says - is there danger in that data?”; that is, our fears are triggered by the word (chemicals) which we have come to associate with danger.

Similarly, people can grasp the specific, and feel the pain, for an individual more easily than for a large, amorphous population. Thus, the outpouring of concern for “Baby Jessica” falling down a well in 1987, or for the child dying of leukemia, is much stronger than that for thousands of people, especially those in other countries, dying of war, disease, or even more abstract, structural violence. It is not just the one versus the many; it is the suddenness of it. We feel for the trapped Chilean miners, or the victims of a bombing; Ropiek says “… a chronic risk doesn’t ring our alarm bells the way a catastrophic, all-at-once one does. Because it concentrates the mind to see a bunch of the tribe all whacked at once.” So a particularly gory battle or atrocity is horrifying, but when there are chronic, repeated bombings and battles (as in Iraq or Afghanistan), even though they lead to much more death, we feel less.

We can see a murderer as a bad person, but it is harder to identify the members of the “grifter class” (coined by Matt Taibbi, “Griftopia”[1] ) who are responsible for the financial system that has visited so much evil on all of us. When people hear about something they know little or nothing about, especially if it is very complex and hard to understand, they often deal with it by putting a “frame” around it, tying it to something that seems similar enough (at least in one dimension) that they feel they can hang their hat on the analogy and judge it. For example, “chemicals=bad” in the example above is such a frame; so is dealing with universal health insurance by framing it as “socialized medicine”=”socialism”=”bad”. Unfortunately, the world is far more complex than this, and more unfortunately unscrupulous politicians and opinion-makers (my frame = “selfish evil people”) take advantage of this to obscure complexity and buy into often nonsensical self contradictions (taxes=bad, deficits=bad; let’s not have either!)

When it comes to health and medicine, the same issues come into play. People perceive immediate distress with acute problems (e.g., cough, fever, and most especially pain!) and know how much they would appreciate relief. The impact of conditions that do not cause appreciable symptoms right now but will cause really bad outcomes (death, morbidity, poor quality of life) if untreated in the future, are much harder to get people to make high priorities. The doctor sees untreated hypertension in terms of a future outcome (stroke, kidney failure), but this is more difficult for the patient. Even when s/he believes and understands it intellectually, it is much less likely that the treatment of a largely asymptomatic condition will rise to the top of life’s many more urgent priorities (food, clothing, housing, childcare, work) than if it were, say, pain.

The problem is even greater for public health, as I discussed in Public Health and Changing People's Minds (Saturday, May 15, 2010) where populations are huge, timelines are long and risk is relative. Public health addresses risks for populations, not me, or my family; translating population risk into individual prior probability is fairly difficult. For most people, even the concept of risk – that a given event will not definitely have or definitely not have a particular result, but will be somewhere on the continuum between them – is something they are not accustomed to thinking about, although they use it all the time (deciding whether to cross on a red light, for example). Consciously comparing the relative risk of different actions is very difficult, especially when the results have very different timelines. A definite immediate benefit (have that tasty fried or sweet food; throw a wrapper out the window, get a big gas-guzzler, have unprotected sex) has a lot more weight than the possibility of a bad long-term outcome (besides, next time, in the future, I’m going to go on a diet, give up smoking, use condoms). Dr. Ropiek notes that because events that cause “a bunch of the tribe to be all whacked at once” happens relatively rarely, “…we tend to downplay chronic risks like car accidents, diabetes, heart disease and the flu.” Sometimes public health officials can create that fear and mobilize the attention of the populace, as with concern about the swine flu of 1976, but that is also an example of how, when predicted risk of bad outcomes doesn’t happen, it reinforces the tendency to downplay those chronic risks.

In making decisions about medical care, this sort of perception can cut either way, depending on how a person looks at it based on personal and familial experience, cultural beliefs, and the way they “frame” medical interventions, as well as how urgent or important a solution is. Some people do not trust doctors or medicines, based on these criteria, and prefer to not take medicines or advice, even when an analysis of the relative risk shows the treatment to be definitely beneficial. Others have unrealistic expectations of what medicine can do (fueled, of course, by both doctors and direct-to-consumer drug advertising), and are angry when the doctor cannot cure their viral illness, make their back pain disappear, or compensate for all of the other parts of life that are bad and make them happy. At times of serious illness, where both treatment and non-treatment have real risks, or at end of life when people are not ready to accept that it is the end of life, even a professional evaluation of relative risk/benefit is difficult, so it is hardly surprising that people return to simpler methods of decision making (will I be able to live another day? Will it end my/his/her pain?).

Hamilton ends the interview segment with: “So Ropiek says we need to acquire a new fear - the fear of getting risk wrong.” I wish us luck on that.

[1] Taibbi, M. Griftopia: Bubble Machines, Vampire Squids, and the Long Con That Is Breaking America. Random House. New York. 2010

Sunday, January 9, 2011

The Arizona shootings: When will we ever learn?

My heart -- and those of my family, many of whom live in her district -- go out to the family and friends of Rep. Gabrielle Giffords, and Judge John Roll and all the other victims of the shooting. As politicians of all stripes have said, it is a tragedy, and the perpetrator is obviously deranged. That said, the irresponsible rhetoric of those who would never do such a thing themselves is inflammatory, and sets off the "weapon", the sacrificial lamb, who carries out the attack. The parallels of this to the assassination of George Tiller are obvious -- politicians, radioheads, and bloviators engage in increasing violent rhetoric and then protest innocence when an unstable disciple carries out a violent attack. Can Sarah Palin deny her "crosshairs" post (now taken down) on her website? Can Jesse Kelly, who ran against Rep. Giffords in 2010 (not to be confused with her husband, astronaut Mark Kelly) deny his posters where he posed in Marine uniform with his M-16 and invited supporters to a shooting event to remove[1] Rep. Giffords? Can Beck, Limbaugh,, deny that their rantings DO affect their dittoheads -- after all, that impact is what boosts their ratings, and their incomes.

And all the protestations that the aggressive elimination of gun control laws in Arizona and other states have nothing to do with guns being used for murder; the swaggering of gun-on-hip posses showing up in coffee shops to intimidate "liberals" not creating an environment where a murderer or assassin can legally be carrying a gun, are vapid. The NRA says "Guns don't kill people -- people kill people." That is true, but people with guns are able to kill more people, more rapidly, from a greater distance. You can bludgeon someone to death, but would John Roll be dead and Gabrielle Giffords in critical condition if Jared Loughner had attacked with a baseball bat? You can kill someone with a knife, but even if Loughner were an action-movie hero and could have thrown his knife with deadly accuracy at Rep. Giffords, would 9-year-old Christina Green be dead? Come on! Be grownups! You can't say one thing -- all guns of all types should be freely available -- and then deny the inevitable result! Well, of course you can, and it is done all the time.

If there is anyone who is eligible to be considered a hero in this tragedy, it is Pima County (Tucson area) Sheriff Clarence Dupnik, who movingly spoke of his friends, and, in what might be a "politically risky" statement condemned the "vitriol" in the public debate that leads to such horror. (Video: The contrast of his obviously pained and saddened but measured, rational speech to the stormtrooper raids of his more infamous counterpart, Maricopa County (Phoenix area) Sheriff Joe Arpaio could not be greater.

We grieve for the dead and the wounded, and we grieve for our country. And we will take it back, our candlelight vigils against their M-16s.

[1] “’I don't see the connection," between the fundraisers featuring weapons and Saturday's shooting’, said John Ellinwood, Kelly's spokesman. ‘I don't know this person, we cannot find any records that he was associated with the campaign in any way. I just don't see the connection.’” (AOL news)

Wednesday, January 5, 2011

Solving Medicare costs and the budget deficit: primary care, cost-effectiveness, and universal health coverage

According to the New York Times,Here is a basic truth about the deficit: In the long run, it cannot be fixed, without reining in spending on Medicare and Medicaid.” In a December 11, 2010 editorial titled “Health Care and the Deficit”, the Times lets us know that Medicare, Medicaid, and S-CHIP (the Children’s Health Insurance Program that covers low-income children whose families are too “rich” for Medicaid) account for more than 20% of federal expenditures, more than Social Security or national defense; and that, if unchecked, will rise to 40% by 2035. To the editorialist this is obviously unacceptable, and s/he reviews the proposals of the two recent “bipartisan” commissions that have made recommendations to reduce spending on these programs.

Overall, the editorial is good in that it is very critical of the recommendations of both commissions. “The most disturbing element of both reports is that, in their efforts to show quick savings, they shift much of the burden from the federal budget to individuals or, in some cases, to states. That may make the federal deficit look better, but it is a shell game that produces no real reduction in the cost of health care.” Bowles-Simpson (the conceived-of-as-a-deficit-reduction-but-changed-into-a-tax-cut panel, previously addressed in my blog of December 12, 2010 Tax Breaks for the "Masters of the Universe" or for the rest of us? ) wants mostly to save money by having greater “cost sharing” by Medicare beneficiaries.

While, as the editorialist points out, there is something to be said for people with any type of insurance not being completely insulated from the cost when they opt for probably-unnecessary expensive tests, the fact is that the fault is much less often on the part of the patient than on the part of the doctors who recommend these tests. This is particularly true when those doctors have a financial interest in doing the tests because they are highly-reimbursed for them. If this is the problem, then regulation should address it directly, by having Medicare, Medicaid, and other insurers use cost-effectiveness criteria rather than taking the real risk that “people on modest incomes might forgo needed care.”

The other panel, Domenici-Rivlin (another “bipartisan” group headed by a conservative Republican and a conservative Democrat), also recommends cost sharing, and goes even further by taxing the cost of health benefits that workers receive. It relies on the idea that, with cost sharing, beneficiaries will restrain their own spending. They are likely to – even at the cost of their own health. It also resurrects the idea of vouchers for people on Medicaid.

Yes: Medicare, Medicaid, and the entire US health system spend too much money; and yes: the cost of what is called “health care” is squeezing out spending on other critical social programs, such as education. But the recommendations of these two commissions, essentially capping spending while continuing to reward private health insurers through their “market-based” solutions, will only exacerbate the problem.

Meanwhile, following on the heels of Massachusetts’ experience in not having enough primary care doctors – or other providers – to meet the health needs of its increased number of insured citizens, California is experiencing the same problem, without even having a state-wide health reform. Documented in the PBS News Hour report aired November 18, 2010, “In California, facing down a family physician shortage”, residents of that state cannot find the primary care doctors they need to provide cost-effective care, and it is anticipated to get “worse” with health reform. Paul Leight, a health economist at the University of California Davis, states “So, we have more than 20 million Americans who now don't have health insurance who will have health insurance. And once they get health insurance, naturally, they're going to want to see a primary care physician.“ Naturally. And we don’t have nearly enough of them.

But, of course, as has been it seems endlessly documented on this blog and by study after study, including for example the Commonwealth Foundation’s 2010 report “Mirror, Mirror on the Wall: How the Performance of the U.S. Health Care System Compares Internationally, 2010 Update”[1], the US spends far more (2-3 times more!) and gets worse health outcomes than all other developed countries. Commonwealth’s 2008 report shows that the US, in terms of health outcomes, did worse than in its original report of 2006, and spending has continued to increase. The biggest reason for the excessive cost in the US is that it is based in a system geared to profit, by insurers, drug and device makers, and health care providers (including hospitals, doctors, nursing homes, etc.) As I have pointed out (for example, in A Modest Proposal: Bribe the Insurance Companies, August 23, 2009), it is not simply the profit itself that causes the grossly bloated cost of US health care, but the inefficient system built to ensure the continuation of that profit. To suggest solutions based on increasing the role of private, profit-incented, players as a method of controlling costs is illogical. Increasing profits will come either from increasing costs or from decreasing access to care. This is not the way to go.

The goal must not be simply reducing costs, but increasing quality. The wonderful thing about health care is that our system is so bloated and inverted in its incentives and outputs – and in having far more tertiary than primary care -- that this seeming contradiction, reduce costs and increase quality, can be achieved. Different groups push for more primary care, limitations on high cost technical procedures, and a more rational health system based upon universal access and elimination of profit. Unfortunately, taken alone, each is inadequate. Here is what the evidence shows will work:

More Primary Care. We need a system based upon primary care, so that Massachusetts, California, and the rest of the country, can have the primary care providers they need. This is the focus of the Patient Centered Primary Care Collaborative (PCPCC). This means completely changing the financial incentives at every level that lead to production of more subspecialists. The “encouragements” for increasing primary care contained in ACA are inadequate. The key issue is the inverted reimbursement system in which procedure-based subspecialists make many times the income-per-hour of primary care doctors. The reimbursement system used by Medicare (upon which all other insurers base their reimbursement), currently controlled by a specialist-dominated advisory group, needs to change entirely so that potential income is eliminated from the specialty-choice decisions of medical students, and so that procedure-based profit is eliminated from the decision of hospitals about what kind of care and specialists they wish to support.

Cost-effectiveness payment. Tied to changing the mix of primary and sub-specialty providers and their reimbursement is for Medicare and other payers to not pay for, or not pay as much for, unproven high-cost therapies, whether those are new drugs or devices or unproven procedures. This does not mean denying access to some procedures or drugs across the board to all patients; it means appropriately selecting those who are most likely to benefit. This is a complex science, but an easy concept: what is likely to be cost-effective for me may well not be for you, because we are different, in disease, disease stage, intercurrent conditions, underlying reserve, etc.

Universal not-for-profit health insurance system. This is the sine qua non, the single necessary element for improving the health of all our people. It is not sufficient in itself, but without it there is no chance to control costs, or to implement reimbursement reform, or to effectively limit the use of high-cost, low-effectiveness and/or unproven technologies.

These will work, but need to all be done. Expanding primary care and limiting expenditures on high-cost procedures will not improve everyone’s health unless we have a university health insurance system that is not based upon profit; a universal health system without increased primary care or cost-effectiveness criteria for procedures will not achieve either goal of improving America’s health or saving money. They are all necessary legs for the stool of cost-effective, high-quality, universally-accessible health care to stand up.

[1] K. Davis, C. Schoen, and K. Stremikis, How the Performance of the U.S. Health Care System Compares Internationally 2010 Update, The Commonwealth Fund, June 2010.

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