The cornerstone of the ACA is the provision for a coverage mandate — whether that coverage includes complete subsidized services (Medicaid or another fed subsidized program) or via private insurer. In order that individual states comply with this most essential of the reform law’s benefits, HHS has announced that states have the option to create “essential benefits packages” as a method of increasing compliance within the ACA.
“Flexebility” is the key, according to Secretary Kathleen Sebelius.
The national health law lists 10 categories of health care that all insurance policies must cover: hospitalization, emergency care, out-patient services, maternity and newborn care, mental health and substance abuse services, prescription drugs, laboratory testing, preventive and wellness care, pediatric services (including dental and vision examinations), rehabilitative care and habilitative care such as services for children with developmental disabilities. But within those categories, the federal government is allowing each state to determine its own basket of essential benefits by choosing a “benchmark” package offered by any of a variety of insurers.
Sebelius: This move protects consumers by respecting states’ role in healthcare delivery under the ACA. Obama administration: This is the only way in which the mandate can be upheld while making essential services affordable in all fifty states. Consumers? Increased standardization among offerings of basic services by states under the ACA raises the possiblity of mandated coverage rather than making things too onerous for the feds in getting the legislation off the ground in just a couple of years. | LINK
With the continued destigmatization of some forms of mental illness in the community (namely, the diagnoses of depression and anxiety), it comes as no surprise that we are more willing than ever to discuss treatment and prevention more openly. Oh, and it also doesn’t hurt that — within the general population at any given time — 10 percent of Americans are taking an antidepressant.
According to the Centers for Disease Control, the rate of antidepressant use has skyrocketed by a factor of 4X over the past 25 years. Females lead the pack in all age demos save for the youngest — ages 12-17. Interestingly, income status was not a predictor of use, the agency cites; although, slightly more than 1 in 12 persons taking the drugs is Caucasian. Most disturbingly, though, is the apparent lack of care access or followup once these drugs are prescribed: just under a third of patients have seen a mental health professional (or primary care physician — assuming the drugs are possibly given for off-label uses) within the previous 12 months. Excellent survey data here.
First, and almost immediately out of the box, it was the concern for serious mental health effects.[1] Now, somewhat controversial smoking cessation drug varenicline (Chantix) is the target of the FDA with respect to the increased risk of heart disease for those taking it. Of course, the FDA rates this as only a “small” risk as it “continues to evaluate its safety”.
The new warning comes from a 700-person trial in which patients who took Chantix (varenicline) over 12 weeks were more likely to experience an adverse heart event after one year than those who received a placebo. All of the patients had already been diagnosed with heart disease. For both groups, the heart attack risk was still small: 7 out of 353 patients taking Chantix had a nonfatal heart attack, versus 3 out of 350 who took a placebo.
Depression and its effects on those preparing for (med students), entering (residents), and established in medicine (attending physicians) are well documented covariates. Among practicing surgeons, a new study in a surgical journal suggests that the link between depression/burnout and suicide is stronger than previously thought.
The high rate of suicidal thoughts among surgeons in particular (6.3% compared with 3.3% for the population as a whole) was “striking,” [the researchers] reported, especially considering that surgeons are highly educated, nearly all have jobs, and most are married — “all factors known to reduce risk of suicide in the general population.”
Another surprise was that older respondents were more likely to report suicidal thoughts — surgeons 45 and older had a rate of suicidal ideation that was 1.5 to 3.0 times the rate among older members of the general population, the researchers reported. The difference was significant[.]
Also, the perceptions of medical errors originating, in part from surgeons themselves, correlated greatly with suicidal ideation. The greater the surgeon perceived the error and its imagined consequences, the higher the degree of correlation. | LINK
Since the late 20th century, innovation in long term care (LTC) has been fueled by a desire of healthcare systems – in this case, owners of skilled nursing facilities — to achieve new quality benchmarks in healthcare delivery at a reasonable cost. Thanks to major pieces of legislation over the past 15 years emphasizing patient safety, healthful outcomes, and cheaper methods of treatment delivery; LTC as a discipline has undergone a sea change for the better. As a geriatrician, I have seen this evolution firsthand. That’s why I absolutely love seeing developments like this
Working with a psychiatrist and a pharmacist, [nurse and resident care coordinator in a Two Harbors, MN nursing home, Eva] Lanigan started a project last year to find other ways to ease the yelling, moaning, crying, spitting, biting and other disruptive behavior that sometimes accompany dementia. They wanted to replace drugs with aromatherapy, massage, games, exercise, personal attention, better pain control and other techniques. [..] Within six months, they eliminated antipsychotic drugs and cut the use of antidepressants by half.
The savings in cost due to the cessation of expensive psychotropics (even if informed consent enabled usage), the avoidance of chemical restraint and its obvious negative effect on patient safety, and the increase in patient quality of life without the need for specialized dementia care (again, at an enormous increase in care delivery cost) are at least three major reasons why innovation in geriatric care is so important in the age of reform. And it’s happening right here in Minnesota. Excellent.
It is well known that in the pre-reform era of mental healthcare delivery, insurers have not treated those diagnoses and their associated coverage on par with those of physical (mostly finite) illnesses. As part of the Affordable Care Act, that’s about to change — albeit, not as sweeping as many advocates would like. Under the Mental Health Parity and Addiction Equity Act (2008), plans are not mandated to provide such services for mental healthcare delivery or addiction services. However, surrogate restrictions on effective coverage — in the form of highly variable copays and deductables — will end…essentially giving parity to a multitude of reimbursable mental health diagnoses.
Although generally pleased with this expansion of coverage, mental healthcare advocacy groups are cautiously optimistic. Insurers can still determine the exclusion of such coverage if they do not deem it “medically necessary” in certain situations (for example, being pre-qualified for services at the outset of one’s care or at a treatment crossroads when one’s coverage includes a change in diagnosis — making his/her coverage trajectory more expansive in the form of, say, more intense outpatient psychotherapies).
Facilitated by the PPACA of 2010, parity of mental healthcare delivery will get another boost — in the form of federal grants designed to increase the integration of such services into the whole of healthcare delivery. | LINK
Most — if not all — state regulatory boards of medicine are able to compel the investigated healthcare provider in virtually all cases that come before them. It took a Massachusetts psychiatrist to challenge that state’s medical board on issues of patient confidentiality. In a case involving the anonymous psychiatrist’s pain management of a handful of patients, the Mass. supreme court ruled that the physician had the right to deny a subpoena by the Massachusetts Board of Registration in Medicine requiring the provider to submit records — nixing the board’s contention that it has a duty to uphold public safety at all costs (safety trumps confidentiality).
Paul R. Cirel, the Boston lawyer who represents the doctor, said in an interview that the board already has access to the records of all controlled substances prescribed by Massachusetts doctors. The ruling, he said, clarifies the state’s psychotherapist-patient privilege and prevents the board from obtaining records about the private relationships between therapists and patients.
The board’s investigation found that the psychiatrist’s narcotic prescribing patterns involved over 200 patients — with over 80 percent being prescribed oxycodone, 77 percent being prescribed diazepam (Valium), and a like number prescribed both. | LINK
I have always viewed as circumspect the interest of certain medical specialty societies which take stands that could be viewed by some as political. The need for these groups to make some sort of societal statement applied to medical corollary without the acknowledgement of the majority of its members implies ever so slightly of a kind of elitism better served by organizations more overtly deemed “political”.
Consider the statement by the APA on the recent effects of the oil spill on the incidence of mental illness diagnoses and subsequent insurance claims for treatment.
Mental illnesses brought on by difficult situations surrounding the BP oil spill may be less visible than other injuries, but they are real. An entire way of life has been destroyed, and this is causing anxiety, depression, [PTSD], substance use disorders, thoughts of suicide and other problems,” said APA President Carol A Bernstein, M.D.
The position – the result of a response to BP’s chief claims administrator essentially denying payment equity with physical ailments payable with the government’s escrow relief funds — sounds more like a pitch to the feds and Big Insurance for more action guaranteeing accessible mental health care under reform. Since the biggest oil fiasco in this country’s history won’t be fading in importance anytime soon, the drive is on for greater awareness of the need for improved access to mental healthcare services.
While there is nothing wrong in actively lobbying the federal government for goals like this — the timing of this announcement, the association with a prominent DC-area mental health lobby, and the strong interest in this particular tragedy (as opposed to other numerous, less newsworthy ones) — should remind healthcare providers of the blurred line between political activism and healthcare advocacy.
Often referred to as the “bible” for the medical discipline of psychiatry, the Diagnostic and Statistical Manual of Mental Disorders, still in its fourth edition overall, is preparing for a makeover — its first since 1994. This was the reference that was the handbook for getting through psychiatric rotations in medical school and residency. Its focus is to provide criteria for diagnosing mental disorders. Incorrectly referred to as a “cookbook” by many, the manual actually stands as complementary to the myriad postulates and patient presentations often part of the challenging workup toward a clinical psychiatric diagnosis.
Scheduled for release in 2013, the fifth edition is now in its final stages of preparation. Starting today, a task force commissioned with proposals for the upcoming edition is now soliciting public comment on proposed changes — which include everything from the proper nomenclature for substance abuse to the increasingly necessary strict determination of the diagnosis of autism. | LINK
The movie The Soloist, starring Oscar winner Jamie Foxx and Oscar nominee Robert Downey, Jr., may have finished behind the Beyoncé flick Obesessed this past weekend in terms of box office, but it is being mentioned in this post for another reason: highlighting a call to action of sorts regarding adult mental illness in this country.
The Soloist is based on the true story of the unlikely friendship between Nathaniel Ayers, a street musician living in Skid Row, and Steve Lopez, a columnist with the Los Angeles Times. In a series of columns, Lopez reports on Ayers’s journey as a gifted student from the Julliard School of Music to the streets of Los Angeles, living with schizophrenia.
Schizophrenia is a mental illness that affects about 2 million Americans — twice the number living with HIV/AIDS. | LINK
This has to be the absolute sanest thing the FDA has done in quite a while: reject a drug (for an indication to treat depression) which appears in the same class as drugs used to treat acute psychosis and chronic schizophrenia (!)
A committee of Food and Drug Administration advisers said Seroquel XR was safe enough for treating some patients with depression but opposed use of the drug for fighting anxiety given the serious side effects.
The panel voted 6-3 that Seroquel XR had acceptable risks if it was added to other medicines to find a workable combination to alleviate depression. Several panel members stressed that doctors should try other treatments for depression first before deciding to add Seroquel XR.
Okay, so the FDA’s stance was not exactly prohibitive on the use of Seroquel to treat depressed mood; it was more conciliatory (almost as if its pharma company requested it)…
The panel split 4-4, with one abstention, when asked if it was safe enough to use Seroquel XR as the only treatment for depression in some cases. Panelists said there were safer medicines that should be tried if only one medicine was going to be used.
Does that mean that physicians **won’t** prescribe it for depression as a first-line? Heck, they already give the stuff for sleep. | LINK
Let’s start this post by harkening back to the dawn of the managed medical care era, just after Medicare and Medicaid programs were about to initially cry insolvency amid a new Nixon administration ready to try anything to put those social programs out of their misery. Back then, the words “doctor” and “trust” were interchangable entities among patients who could come to appreciate their care and expect a (reasonably) long and healthy relationship.
Fast forward a good forty years, and those government programs are still churning, albeit with major financial baggage gumming up the works; and patients no longer expect primary care with a singular provider from cradle to grave. As a Broken Health Care Nation, patients as consumers have come to expect nothing less.
But can the same thing be said about primary mental healthcare? What is probably seen as a boundary-busting dysfunctionally enabling relationship among client and provider by anonymous bean counting third parties is a closely guarded dyad steeped in trust and sanctimony by those same patients and their committed mental health treatment team.
It’s precisely this issue of trust which is at the center of the fight between a District of Columbia’s city council decision to close publicly funded mental healthcare clinics in favor of private contracts for those patients whose trust in that care delivery model is solid. To say that they have to deal with the alternative is laughable, and they came out in full force to protest the proposed action. | LINK
Originating from Saint Paul, Minnesota, [doctorpundit.com] is a weblog about the policy of healthcare and where it intersects with politics and public opinion; it is edited by Michael Douglas, MD, MBA. Welcome, and please consider my take on what is Healthcare 2.0, complemented by a few of my thoughts on my personal avocations and guilty pleasures: music, prose, and writing. Follow Doctor Pundit via RSS above.
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DOCTOR PUNDIT @ ONE YEAR | An occasional DP series from 2010 highlighting healthcare policy trends over the period from 2009-2010 in a compare/contrast format.
