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Welcome to my blog, a place to explore and learn about the experience of running a psychiatric practice. I post about things that I find useful to know or think about. So, enjoy, and let me know what you think.


Monday, April 21, 2014

Emotional Abuse

A recent post on The Practical Psychosomaticist, ACEs Study: Guest Blog by Dr. Resmiye Oral, described the significant medical morbidity and mortality that results from childhood abuse. Clearly, if something can be done about the abuse, the general population would be much healthier.

As described in the ACEs study, abuse included Physical, Sexual, and Emotional. To my thinking, physical and sexual abuse are much easier to define and recognize than emotional abuse. (I'm not saying there aren't equivocal cases, but on the whole).

So I started wondering about the definition of emotional abuse. And the answer is, it's complicated.

First off, the terminology. There are a number of synonymous phrases that describe something like emotional abuse. These include psychological abuse, mental cruelty, psychological maltreatment, emotional neglect, mental injury, and psychological battering. These terminological differences reflect, among other things, differences in intention. For example, emotional neglect as an act of omission, rather than commission.

Some authors (O'Hagan, K. (1995), 'Emotional and psychological abuse: problems of definition', Child Abuse and Neglect, vol.19, 449 - 61; and (1993), Emotional and Psychological Abuse of Children, Open University Press, Buckingham.), differentiate between emotional and psychological abuse in terms of their effects. Emotional abuse as,

"The sustained, repetitive, inappropriate emotional response to the child's expression of emotion and its accompanying expressive behaviour. " This type of abuse impacts the child's affective development.

Whereas Psychological abuse is defined as "sustained, repetitive, inappropriate behaviour which damages, or substantially reduces, the creative and developmental potential of crucially important mental faculties and mental processes of a child: these include intelligence, memory, recognition, perception, attention, language and moral development".

However, other authors (Higgins, 2005) argue that "the degree (frequency and severity) to which young people experience abusive/neglectful behaviours is more important than the particular subtype of maltreatment in explaining subsequent psychological problems," so that distinctions between type may not be that significant.

One definition (Garbarino, J., Guttman, E. and Seeley, J.W. (1986), The Psychologically Battered Child, Jossey-Bass Publishers, California) classifies Psychological Maltreatment into 5 forms:

  • rejecting: behaviours which communicate or constitute abandonment of the child, such as a refusal to show affection;
  • isolating: preventing the child from participating in normal opportunities for social interaction;
  • terrorising: threatening the child with severe or sinister punishment, or deliberately developing a climate of fear or threat;
  • ignoring: where the caregiver is psychologically unavailable to the child and fails to respond to the child's behaviour;
  • corrupting: caregiver behaviour which encourages the child to develop false social values that reinforce antisocial or deviant behavioural patterns, such as aggression, criminal acts or substance abuse.
More recent additions include "...forcing children to live in dangerous and unstable environments (e.g. exposure to war, domestic violence or parental conflict); and the sexual exploitation of children by adults and parents who provide inadequate care while under the influence of drugs or alcohol." (Garbarino and Vondra, 1987)

There is general consensus that Emotional Abuse does not result from isolated incidents of parents losing their tempers. If it did, every child would suffer from it. The real damage lies in the chronic, sustained, and repetitive nature of the behavior.

It is also important to note that while emotional abuse can exist on its own, rarely (probably never) does physical or sexual abuse take place without an emotional component. 

Yet another complicated aspect of emotional abuse is context. In some cultures, chronic criticism is viewed as affectionate, the parent's way of demonstrating to the child that he is WORTH criticizing, that she has the potential to be even better. 

This brings up the question of goodness-of-fit. One child raised in such a culture may recognize the implicit caring, another may simply feel crushed. This is the case not just in varying cultures, but in varying parenting styles, where normative parents may not mesh well with the temperament of their normative child. Similarly, the same parental behavior may affect a child differently at different ages/developmental stages.

The effects of emotional neglect can be extensive. You may recall Rene Spitz's paper, "Hospitalism", where he writes about the infants in a Foundling, who received adequate physical and medical care, but who were emotionally neglected due to unavoidable constraints (1 nurse provided full-time care to 8 babies). There was an astronomically high rate of illness, failure to thrive, and mortality among these children. And the damage was irreparable.

In a later, heartbreaking paper (Spitz, R.A., Wolf, K.M. (1946). Anaclitic Depression—An Inquiry Into the Genesis of Psychiatric Conditions in Early Childhood, Ii. Psychoanal. St. Child, 2:313-342) Spitz describes in greater detail the anaclitic depression of these infants:

These children would lie or sit with wide-open, expressionless eyes, frozen immobile face, and a faraway expression as if in a daze, apparently not perceiving what went on in their environment. This behavior was in some cases accompanied by autoerotic activities in the oral, anal, and genital zones. Contact with children who arrived at this stage became increasingly difficult and finally impossible. At best, screaming was elicited.

A more recent paper, Emotional but not physical maltreatment is independently related to psychopathology in subjects with various degrees of social anxiety: a web-based internet survey
examined longer term effects of emotional abuse, and showed that:

...parental emotional maltreatment and emotional peer victimization were independently related to social anxiety and mediated the impact of physical and sexual maltreatment. Subjects with a history of childhood emotional maltreatment showed higher rates of psychopathology than subjects with a history of physical maltreatment.

Unfortunately, emotional abuse remains hard to identify.

Emotional abuse that exists independently of other forms of abuse is the most difficult form of child abuse to identify and stop. This is because child protective services must have demonstrable evidence that harm to a child has been done before they can intervene. And, since emotional abuse doesn’t result in physical evidence such as bruising or malnutrition, it can be very hard to diagnose.

There may be identifiable developmental delays and emotional problems, but these can exist independently of any abuse, and so are not diagnostic.

Given the scope of the ramifications of this type of abuse, as described in the ACEs study, including smoking and all its sequelae, other substance misuse, and unwanted pregnancies, this is an area that deserves extensive inquiry.


Friday, April 18, 2014

Documentation of Time

I thankfully haven't felt the need to write anything about E/M coding in a while. But there seems to be an important update.

The NYSPA will host a Psychotherapy Documentation Update Webinar on April 29th (I couldn't find any information about it on the NYSPA site, so the link is to the registration form):

NYSPA will be hosting a webinar to update members on new documentation requirements requiring documentation of psychotherapy time. The webinar will address the new Medicare and Optum policy on documentation of time. Discussion will include the revised NYSPA template, status of health plan audits and parity issues.

It's free to NYSPA members, and $250 for non-members. And it will be posted to the website afterwards, for those members who couldn't make the webinar.

Time has been a bit of a sticky point in terms of E/M, CPT coding. A lot of people were concerned about the requirements to document time spent doing psychotherapy separately from time spent doing Evaluation and Management. When I attended the coding seminar given by NYSPA, we were assured that since psychotherapy is not a separate event from evaluation and management, the times for the two should just be mushed together.

Apparently, United Behavioral Health/Optum was denying claims for just this reason:

Optum was refusing to provide reimbursement for the psychotherapy add-on code because the provider had failed to document start and stop times for the psychotherapy portion of the session alone (as opposed to the E/M portion). This practice, clearly in violation of CPT, was being applied to both in-network and out-of-network benefits. (Source, from NYSPA)

NYSPA was contacted, and the APA got involved, and ultimately:

UBH/Optum... acknowledged that the new combination psychotherapy codes represent the provision of a single integrated service that cannot and should not be separated out.   As a result, UBH/Optum will discontinue its requirement that psychiatrists record the time spent providing psychotherapy alone. ...Please note, however, that proper documentation of psychotherapy must include session start and stop times and/or the total face-to-face time spent with the patient. (Same Source).

Optum subsequently sent a letter to providers confirming E/M documentation guidelines.

I'm not sure what the webinar will cover with respect to medicare documentation. My take home lesson is: Include start and stop times in my notes.

And while I was poking around the cms.gov site looking for and not finding information about documenting psychotherapy time, I did find:

Medicare Coverage of Items and Services Furnished to Beneficiaries in Custody Under a Penal Authority Crossword Puzzle. (The link goes to the page that links to the zip file with the pdf of the puzzle.) It looks like this (so you know I didn't make it up):











Wednesday, April 16, 2014

The Nose Knows

I'd really like to just gloss over this topic, but I can't bring myself to do so. Have you read about "Sluggish Cognitive Tempo" (SCT)?

Check it:

...powerful figures in mental health are claiming to have identified a new disorder that could vastly expand the ranks of young people treated for attention problems. Called sluggish cognitive tempo, the condition is said to be characterized by lethargy, daydreaming and slow mental processing. By some researchers’ estimates, it is present in perhaps two million children.

Experts pushing for more research into sluggish cognitive tempo say it is gaining momentum toward recognition as a legitimate disorder — and, as such, a candidate for pharmacological treatment. Some of the condition’s researchers have helped Eli Lilly investigate how its flagship A.D.H.D. drug might treat it.

And there it is, black on white. Researchers helping Lilly market a drug. Really, "identified a new disorder"? Like what, they found a new bacteria under a microscope?

Here's Allen Frances' comment from his article, No Child Left Undiagnosed:

"'Sluggish Cognitive Tempo' may possibly be the very dumbest and most dangerous diagnostic idea I have ever encountered."

Right on Dr. Frances!

When I googled "Sluggish Cognitive Tempo", the first thing that came up was itself, followed by sluggish thyroid and sluggish bowels. I'm not sure what that implies. Anyway, SCT was the main topic in the January 2014 issue of the Journal of Abnormal Child Psychology.

According to the introductory article, SCT is characterized by "drowsiness, daydreaming, lethargy, mental confusion, and slowed thinking/behavior". Then there are a couple articles about the validity of SCT, and more discussing the relationship with ADHD.

One article I found, Symptom Properties as a function of ADHD Type: An Argument for Continued Study of Sluggish Cognitive Tempo, by McBurnett et al,  published in 2000, noted that SCT had been discarded from the inattention symptom list in the DSM IV Field Trials, due to poor negative predictive value. But then McBurnett et al decided to look at SCT again, and found that "Sluggish Tempo Items showed substantially improved utility as symptoms of Inattention, " and that a "Sluggish Tempo factor could be distinguished from an Inattention factor." It wasn't clear to me from reading the abstract why they decided to take another look at SCT.

The thing is, even if SCT is a "real thing", even if a child can "have" SCT, who says that child needs a label, or meds, or even treatment?

Note also the messy interaction between Allen Frances' opinion about SCT and his role as chair of the DSM IV task force. Maybe he does have a conflict of interest. I still think he makes more sense than this crusade to label every aspect of the human condition as pathology.

What's next, pathologic nose-picking?

1. Nose-picking at least 3 times per day, present most days, for at least 2 weeks.
    Specify:
                     a. Booger-Eating Type or      
                     b. Non-Booger-Eating Type

2. The patient is often unaware of the nose-picking behavior while it is happening (in children, the  behavior may be noted by a family member or teacher)

3. The nose-picking does not take place in the context of recent trauma to nose.

4. Nose-picking is not a culturally accepted norm for the patient.

5. The nose-picking is not better explained by another condition, such as OCD.

6. The nose-picking causes significant distress for the patient or patient's family, such as frequent    nosebleeds, teasing at school, or booger-encrusted undersides of furniture.





 





Monday, April 14, 2014

Beliefs

Sometimes, when I'm in a session with a patient, I wonder how to address beliefs I don't agree with.

It gets pretty complicated. There's the whole issue of religious beliefs. People are entitled to believe in a deity, if they're so inclined. I am curious about these beliefs, particularly if they are significant in a patient's life, and I will certainly ask about them, and encourage the patient to discuss them. But is it appropriate for me to "reality test" when it comes to religious beliefs? Like, "Come on! Do you really believe in resurrection, or weird things happening to large bodies of water (splitting, turning to blood, etc.)?"

Let's assume I lay off religious skepticism. Religions are, after all, culturally acceptable and common phenomena. But what about related ideas, like ghosts? Lots of people believe in ghosts. Is it my place to say, "You're an otherwise rational person, so what's up with the ghosts?"



I don't know the answer to that, but the bigger problem for me is, what about when it comes to health related issues. Like homeopathy. Or crystals.

What if I think these beliefs are dangerous? Like, "My 15 year old son has been having leg pain that's waking him at night and causing him to limp, so I'm taking him to a chiropractor who's giving him orthotics to correct his alignment. No, he didn't have an x-ray, the chiropractor said that would be too much radiation exposure." (A variation of this happened to someone I know, not a patient. Luckily, it wasn't neoplastic, but it did require surgery, and months of pain could have been avoided with a simple, inexpensive x-ray.)  If I were a pediatrician, I would never let that one go unchallenged. But as a shrink, doing therapy, or analysis, I'd be crossing a boundary to say, "Your kid needs an x-ray. Take him to his pediatrician. If he's cleared, then you can go ahead and spend lots of money on useless shoe inserts."

In general, I take the position that if my patient is about to do something I think is a mistake, if I believe it's dangerous, I say something. Otherwise, I don't. But "dangerous" can mean a lot of things. And even when I do say something, I try to be as neutral as I can.

In practice, this is difficult. "Have you discussed this with your pediatrician?" certainly implies that I think my patient OUGHT to discuss this with the pediatrician, so it's not so neutral, but it's better than osteosarcoma that could have been caught early on if only I had said something.

Lately, the issues that have been making me think about this topic have to do with diet. Gluten. Organics. Supplements. Toxins. What is WITH the whole gluten-free thing? Yes, some people have celiac disease, and THEY shouldn't consume gluten products. But just because gluten is bad for them doesn't mean gluten is bad for everyone! It drives me crazy.

And hey, if a hemp oil, flax seed, kale, pomegranate, agave smoothie is your thing, go for it! But if you're drinking it because your current guru claims it will "cleanse you of your toxins", maybe we need to examine why you're so willing to believe this.

I think there are a couple of take home points here:

1. It's a good exercise for me not to feel like I have to agree with everything my patients think or do, or to "correct" them.

2. It's good for my patients to feel safe enough that they can share their beliefs with me, and question the ones that may be causing them problems.

3. Belief is a remarkable phenomenon. People are so willing to believe in the latest health fad, even with poor or no scientific evidence to support it. Bad Science by Ben Goldacre is a good read on the topic of pseudoscience.
I think it goes beyond "sciencey" sounding ideas, though. I think what it comes down to is that we all worry about our well-being, our health, our diet, and by extension, our mortality. And in the face of this worry, we long for certainty. Doctors don't provide certainty. Likelihood in some cases, but not certainty. In fact, I consider it part of my job description to help my patients learn to tolerate uncertainty.
People hawking homeopathic remedies or miracle cures sound pretty sure of themselves. THIS will definitely help you live longer, feel better, boost your immune system (why doesn't it occur to most people that we'd die pretty quickly of an immune system boost?), improve your life. What a comfort that is.

'I love you" is a scary three word phrase.

"I'm not sure" is scarier.

Maybe.





Thursday, April 10, 2014

Noteworthy

I got an email from a company called, Software Advice, that provides free recommendations to anyone interested in adopting a new business software system. The company's income source seems to be the software vendors:

Software Advice is 100% free for software buyers. We get paid when we make a good match between a software buyer and a software vendor.

Anyway, the email asked me to take a look at their report, entitled, Mental Health Meaningful Use Market Share IndustryView | 2014. There's also a nice slideshow:


Mental Health EHR Market | MU Attestations from Software Advice


Before I comment on the report, let me answer a question: Why am I writing this? Because I thought it was interesting, because they asked nicely, because the report is well-written and gives due consideration to its limitations. NOT because I'm promoting the company-I guess I'm okay with it if they get more business as a result, but you can take it or leave it, and I certainly have no intention of finding a vendor through them, especially since I already have a free EMR system that I don't use. And NOT because I'm getting paid to do so-I'm not.

There. I said it.

The report looks at the number of providers in psychiatry attesting to meaningful use of an EHR system, and compares 2012 to 2013 results, which were recently released by the CMS.


I haven't written about meaningful use, largely because I'm not a medicare provider, so I'm not affected by it. Briefly, providers (also hospitals) who incorporate an EHR in their practices are eligible for incentives to help cover the cost of implementing the EHR. In order to receive these incentives, they have to demonstrate "meaningful use", which has 3 separate stages and numerous "quality assessment" requirements, see the link if you really want to know the details. In addition, starting in 2015, medicare providers who do not demonstrate meaningful use will receive payment deductions in their medicare reimbursement.



The report also found that the number of Mental Health EHR vendors increased from 2012 to 2013.



This is where things start to get interesting, because it's expected that in the not-too-distant future, there will be consolidation of EHR vendors. There are now too many platforms to be sustainable, many providers are dissatisfied with their current systems, incentive money is drying up, so the bigger fish will buy out the smaller fish, or the smaller fish will just go belly-up.
There's also the issue of interoperability. Say a physician in private practice uses one EHR system, but the hospital he's affiliated with uses another. At some point, these two systems are going to have to share information about common patients, so how do they do that? In all likelihood, the EHR systems that will win out will be the ones with the most flexibility, that can facilitate connections with other systems.

It'll be like Kindle vs. Nook, or VHS vs. Beta, or Cassette vs. 8-track.


So the question is, why were there more Mental Health EHR Vendors in 2013 than there were in 2012?

One reason may have to do with one of the limitations of the report (I'm not getting into most of them, but it's not a long document, and it delineates many of its own shortcomings, so you can check it out for yourselves). There are plenty of psychiatrists who don't accept medicare, and who are, therefore, not interested in any meaningful use attestations, and whose use wouldn't be accounted for.
Also, most EHR's aren't very user-friendly for clinicians. They seem to be designed mainly for billing purposes, which leaves out the real function of a patient record. Could vendors be expanding in the hope of tweaking their systems to be more usable, and wanting to be on the forefront, testing their systems with those who are interested in meaningful use qualification, but really aiming for a larger audience, including non-medicare providers?
Or are they expanding so they can take advantage of the surge in meaningful use providers, with a plan to consolidate once that bubble bursts?
Puzzling.

And speaking of notes. The following is the transcript of a 2 page note written, by hand, in 1981. The patient was a relative of mine, now long dead, so this is not a confidentiality violation. I found the chart in a bunch of old papers I was going through. The note is a consultation by a "Radiation Therapy Attending", and it's the real reason I was interested in writing a post about electronic note systems. I'd like to see an EHR spit this out:

52 white male with soft tissue sarcoma R distal thigh. This presented as a painless lump~early 4/81. Needle Bx was nonDxic. Incis Bx 5/22/81 shows a high grade pleomorphic sarcoma, ? rhabdo. Subsequent studies include normal counts, SMA 6/12, bone and liver scans. CXR 5/21/81 showed a 1.1 cm RUL lung nodule, new since CXR of 1/81. This was confirmed by tomog, which also showed a 1 cm LLL nodule; both appear to be mets. (- PPD, no Hx lung disease, cigs 1 ppd x 20y). CT scan of thigh 5/27 showed ~ 10 cm nonenhancing lesion without evidence of bone or vascular invasion. Arteriogram  today showed an 11 x 6 cm highly vascular mass beginning just proximal to R medial condyle; scalloping of popliteal A could represent tumor encroachment.

PE: Well appearing man in NAD, alert, oriented, normal neuro, heart, lung, abdomen, testes. Extrem WNL except firm 9 x 9 cm mass R distal medial thigh with healing 5 cm incision. Mass blends into underlying M of vastos medialis and extends 3 cm distal to incision (just prox to medial condyle) and 1 cm prox to incision, 2 cm post-lat to incision and 9 cm (circumferentially) medial to incision, being just medial to midline. There is a soft 1 cm R inguinal node ? (I can't read this word), no popliteal or other adenopathy. Pulses, M strength, joint function are all good.

Assess: Pleomorphic sarcoma R thigh, G3T2N0M1. LAG pending (was + in 66-89% of children with extremity rhabdo).

Recommend: Begin with chemoRx to try to eliminate micromets and evaluate response of primary, nodes and lung nodules (Children with rhabdo often get good response to VAC-eg Intergroup/Rhabdo Study, Maurer et al, Cancer 40:2015-2026, 1977 had 50% CR and 30% PR, some still in CR at 1y, few at 2y. Also Harvard: Dritschilo et al, Cancer 42:1192-1203, 1978, VAC and lung RT and primary RT +/- conservative surgery, 96% local control. Adults (variety of soft tissue sarcomas) have had 10-12% CR and 45% PR with adria-DTIC +/- CTX and VCR or adria-methyl-CCNU--both SWOG studies, Benjamin et al. pp. 309-315 in Management of Primary Bone and Soft Tissue Sarcomas, year Book, 1977, and Rivkin et al, Cancer 46:446-451, 1980.)(boldface mine)

If he responds well to chemoRx, suggest conservative surgery of R thigh and RT~ 5000 rads R medial thigh from knee to groin +/- iliacs (depending on LAG) and boost of primary to ~6000-6500 rads. Would also consider low-dose whole lung RT ~ 1500 rads/ (can't read) and boost to nodules. If he progresses on chemoRx, then palliative RT +/- chemoRx. Would like to reevaluate in 3-6 weeks. 

Let me reiterate, this was a hand-written note, including all the citations. I've never seen a note like this in any chart I looked at throughout my training. If Software Advice can find me an EHR that can generate this, then I WILL do business with them. But I think the days when a consultant would write this kind of note are long gone. And really, the key isn't the note, it's the doctor who wrote it. 

Sunday, April 6, 2014

APA-thetic

I'm becoming increasingly, shall we say, disenchanted with the APA. Even more than I was when I terminated my membership a couple years ago.

The latest escapade contributing to my disenchantment is the Milliman American Psychiatric Association Report, Economic Impact of Integrated Medical-Behavioral Healthcare, Implications for Psychiatry. For some reason, I can't get an independent link to come up for this-it just generates a pdf in my downloads file, but there are links to it, and its summary HERE.

This is a 39 page document prepared for the APA by Milliman, Inc., a firm that provides "actuarial and related products and services". It reads like a piece of PR, wonder why. Phrases like,

The field of psychiatry is poised to become a major participant as IMBH evolves. Psychiatry has a direct role in the value proposition of integrated/collaborative care and stands to benefit from the savings generated by effective integration programs.

are what make me think so.

They estimate that somewhere between $26.3 and $48.3 billion can be saved annually through use of integrated medical/behavioral healthcare systems, like collaborative care.

First, they proceed to demonstrate how they came up with those figures. I'll attempt not to be too detailed, but they claim that, "Medical costs for treating those patients with chronic medical and comorbid mental health/substance use disorder (MH/SUD) conditions can be 2-3 times as high as (for) those beneficiaries who don‘t have the comorbid MH/SUD conditions. The additional healthcare costs incurred by people with behavioral comorbidities are estimated to be $293 billion in 2012 across commercially-insured, Medicaid, and Medicare beneficiaries in the United States.

Significantly,

"Most of the increased cost for those with comorbid MH/SUD conditions is attributed to medical services (more than behavioral), creating a large opportunity for savings on the medical side through integration of behavioral and medical service."

My question is, "How? "

Some of the figures are interesting. I should mention that I basically believe their figures, just not their conclusions, but who knows. They looked at 3 types of insurance, Commercial, Medicare, and Medicaid, and divided these into populations, and then researched how much was spent on each population. Commercial and Medicare were divided into 4 populations: No MH/SUD; non SPMI (severe and persistent mental illness) MH; SPMI; and SUD. Medicaid was divided into No MH/SUD and MH/SUD.

Here's a screenshot of Per Member Per Month Costs per Population for the Commercially insured:




You can see that a lot more is spent on medical care for those with Mental Health and Substance Use problems ($750, average), than for those without ($280).  What I've highlighted is incidental but interesting. $23 per person per month is spent on those with a Non-SPMI MH diagnosis for behavioral treatment, vs. $74 for behavioral meds. In the SPMI population, it's $128 vs. $175.

That's 3 times as much for meds than for other behavioral care in the Non-SPMI MH group. Tell me, what kind of therapy does $23 a month buy? And this is commercial insurance we're talking about, not medicare or medicaid.

In fact, medicare spends $579/month, and medicaid spends $309/month on medical care for Non-MH/SUD, vs. the $280 for commercial insurance. And medicaid spends $286/month on non-pharmacologic behavioral care for those with MH/SUD diagnoses, vs. an average of $75/month spent by commercial insurance. Maybe this is because those with medicare and medicaid tend to be sicker than those with commercial insurance.

Here's another chart with my highlights:




Why are behavioral facility costs roughly the same for those with a Non-SPMI MH diagnosis, and those without? And why are professional behavioral costs for No MH/SUD ($3690) actually greater than costs for SPMI ($3457)? Are there patients who are receiving behavioral treatment without a behavioral diagnosis? And if so, how are providers coding and being reimbursed?

Let's move on to the heart of the document. How can this data help us to provide better and more cost-efficient care in an integrated care model? The answer is something called, Value Opportunity, which is, "The potential for savings if we could manage all of a patient‘s comorbid conditions more effectively."

For example:



The value opportunity for chronic kidney disease is, "$2,251 PMPM ($6,901 - $4,650) additional healthcare spending for those treated for substance abuse and $1,582 PMPM ($6,232 - $4,650) additional costs for those treated for Non-SPMI conditions."

So all we have to do is cure patients of their Mental Health and Substance Use Disorders, and that will put them into the No MH/SUD population, so then their medical costs won't be as high. Right?

The bottom line:

Across all populations (commercial plus Medicare plus Medicaid), we estimate a total annual value opportunity of $293 billion through integration of behavioral and medical services in the U.S.

Well gee, Mr. and Mrs. Milliman, that's a lot of money! Will integrated care really be able to produce this result?

Yes, my boy.

For example:

"The Pathways study focused on the outcomes of a program utilizing specialized nurses to deliver a twelve-month depression treatment program for patients with diabetes. This program was administered through a randomized controlled trial that compared the systematic depression treatment program with care as usual. Total outpatient costs were approximately equal during the 12-month intervention period for both the intervention group and the usual care group, but during the 12-month period following the intervention, median outpatient costs for the intervention group were $50 PMPM lower than costs for the usual care group. Over the entire two year period, including the intervention period, total healthcare costs (including inpatient and outpatient health services) were $46 PMPM lower for the intervention group than for the usual care group. This represents savings of about 5% of total healthcare costs for the intervention group over a 2 year period."

Hold on, there! Where does the $50 PMPM come from? Is it savings in medical care for diabetes?

According to the abstract (check the link to the study, above):

Conclusion: The Pathways collaborative care model improved depression care and outcomes in patients with comorbid major depression and/or dysthymia and diabetes mellitus, but improved depression care alone did not result in improved glycemic control.

In fact, most of the abstract doesn't jive with the description above. Maybe they did a follow-up study that I didn't find.

The Milliman document also cites the Multifaceted Diabetes and Depression Program (MDDP) study.

"Although not statistically significant, medical cost savings of approximately $39 per member per month (PMPM) were observed during the eighteen months following the implementation of the MDDP program." (emphasis mine)

They also cite the IMPACT Study, and state that, "Total healthcare costs were tracked for a 4-year period following the intervention, and costs for the intervention group were an average of $70 PMPM lower than costs for those receiving usual care. This represents savings of about 10% of total healthcare costs for the intervention group over a 4 year period. Patients in the collaborative care management program had lower costs in every category that was observed, and the results of a bootstrap analysis indicated that patients in the collaborative care program were 87% more likely to have lower total healthcare costs than those receiving usual care."

I don't like the "total healthcare costs" phrase. Where was the money saved? In "every category that was observed"? What is this "bootstrap analysis"?

IMPACT studied interventions for depression in the elderly, in primary care settings. It found that depression improved over 12 months. That was the stated purpose of the study. Outcome measures assessed depression, depression treatments, satisfaction with care, functional impairment, and quality of life. The study was not designed to test healthcare spending.

They offer a couple more fumpfed examples, but here's the OMG kicker:

The American Medical Association estimates that there are 41,784 psychiatrists practicing patient care as of 2012. The Bureau of Labor Statistics estimates average annual earnings of $174,170 per practicing psychiatrist as of May 2011. This translates to $7.3 billion in psychiatrist wages annually. Comparing this estimate to the projected savings estimate of $26-48 billion means that the potential financial impact of IMBH programs can be up to 3.5 to 6.6 times annual psychiatrist earnings. Stated another way, a 10% gain sharing arrangement for psychiatrists (where they are credited with a certain percentage of actual achieved healthcare cost savings through a contractual arrangement) of savings from integration has the potential to increase annual earnings estimates for psychiatry overall by about 50%. In this example, that leaves the other 90% of savings through collaborative care to be shared with others in the collaborative care teams, to be used to lower healthcare premiums, and to be reinvested in community based care.

APA, I'm so over you.


Saturday, March 29, 2014

Silence

The idea for this post came from a reader who prefers to remain anonymous, but I did want to give due credit, so, you know who you are, and thanks.

Silence is very important to me, both professionally, and personally. I'm pretty sure I picked the right profession for myself, because I don't much like talking (I do like listening), and I'm comfortable sitting silently with patients.

As an aside, one of the attendings from my residency did his residency, way back, at Menninger, when the Menninger brothers were there. So he was surrounded by a lot of analysts for 4 years, and he told me, "For people who spend their days listening, when you get them in a room together, they sure do like to talk."

I have found this to be true, but maybe not to the extent I formerly believed. In one of my first analytic classes, we read a paper about choosing patients who are appropriate for analysis. When I walked into the classroom, before class started, the guy teaching the class asked me what I thought of the paper. So I summarized. "You can't be too sick, you can't be too well, and you never know 'til you try." At the time, I thought that was pretty much everything there was to say about the paper, even though we went on to discuss it for 1 1/2 hours.

Now I'm not so sure. Maybe it has something to do with the value analysis places on language-it is, after all, a "talking cure" (Note that the phrase was coined by Bertha Pappenheim, AKA Anna O, while she was being treated by Joseph Breuer for hysteria. Hers is the first case recorded in Studies On Hysteria, by Breuer and Freud). Or maybe it has to do with the fact that the more time you spend listening to a person, the more you discover how much more there is to know about that person. And the same is true for most, if not all subjects. The more you know about a subject, the more complex you realize it is. So if I thought there wasn't much to say about that paper, it was probably a reflection of my ignorance.

What about silence? It's not the therapeutically exclusive provenance of psychoanalysis. It happens often in face-to-face therapy, and it may even be more difficult to tolerate in that setting than in analysis, where both the analyst and analysand are protected by the lack of eye contact.

Silence can take on many meanings in a therapeutic setting. For the patient, it can be withholding and aggressive, as in, "You can't make me talk!" It can be a form of hiding, as in, "I'm ashamed of my thoughts and feelings, so I'm not going to humiliate myself by sharing them." It can be an attempt to level the playing field, "You don't tell me anything about yourself, so I won't tell you anything, and that way I won't feel helpless and inferior."

It can also be an expression of trust, "I'm comfortable enough with you that I don't feel obligated to entertain you or be socially appropriate by babbling or trying to make conversation." And it can represent an attempt to share an experience or idea that is difficult to verbalize.

Patients have feelings and thoughts about the therapist's silence. It may be seen as punitive, humiliating, rejecting, abandoning, empty, containing, comforting, and many other things.

Therapists also have views about their patients' silences. Are they being hostile, or controlling? Are they confused? Are they attempting to sort through some experience that has not existed for them in the verbal sphere? Are they frightened? Am I doing something wrong? Am I doing something helpful? Do they need me to say something? Am I distracted and therefore have nothing to say?

These questions obviously reflect therapists' feelings about their own silences.

One important question is, why is silence often experienced as uncomfortable? The straightforward answer is, because that's not what people do in normal social interactions. But why is that? What's wrong with not talking? It's true, we're social beings, but speech is not the only form of communication.
At parties, people who don't talk much are considered uninteresting. In many educational settings, children who prefer to take in a discussion and not comment frequently are often thought to not be paying attention. And in medical school, when I was in new, complicated settings like the OR, or the ICU, and was asked by residents or attendings if I had any questions, I usually didn't because there was so much new information to absorb, I hadn't yet reached the point of being able to formulate a question. This was sometimes viewed as evidence of lack of interest on my part.

So we can agree, I think, that both silence and speech are complicated. One thing I wonder is, what happens when clinicians not only don't have time to talk with their patients, but don't have time to sit in silence with them, either?


These are some interesting quotes about silence, that I found on PEP-Web:

From the APSaA Winter Meeting, 1948:

CHAIRMAN: President William C. Menninger, M.D.
2:00 P.M. Robert Fliess, M.D. (New York): Silence and Verbalization: On the Theory of the Analytic Rule.
Discussants: Therese Benedek, M.D. (Chicago); Robert C. Bak, M.D. (New York)
Author's Abstract: Verbalization releases regressive affect, collateral to repressed ideation, thus interfering with the maintenance of repression. The speech-apparatus is substituted for different erotogenic zones, whereby speaking becomes excretory instinctual discharge, words excretory product, and silence equivalent to sphincter closure. Technical and theoretical consequences deriving from these “pleasure-physiological” considerations are discussed.


Greenson, R.R. (1961). On the Silence and Sounds of the Analytic Hour. J. Amer. Psychoanal. Assn., 9:79-84

The most frequent silence met with in psychoanalytic practice is the silence of resistance. This silence means that the patient is either consciously or unconsciously unwilling to verbalize. Since the patients in our psychoanalytic practice are attempting to communicate to us in accordance with the basic rule, i.e., attempting to put all their thoughts into words, if they become silent, it means that they are opposing the procedure of psychoanalysis. It is then our task to overcome this obstacle by attempting to find the motives for this resistance. Here, we are often aided in our task by the fact that the patient communicates despite his resistance...
Silence, however, may not only indicate a resistance to a certain content but may itself be the content which the patient is trying to convey. For example, patients may fall silent during an analytic hour when they are unconsciously repeating some historical event in which silence was an important element. Primal scenes and primal auditions often make their first appearance in the analytic hour as a restless, agitated, wide-eyed silence. The patient is repeating in the presence of the analyst the silent excitement and anxiety of the primal experiences.
Silence may indicate an identification with a silent object. This happens frequently in the analysis of candidates, who in this way identify with their silent analyst. This should be kept in mind when the silent patient seems to be not only comfortably silent, but confidently and poisedly silent. Furthermore, silence can represent an identification with an inanimate object, a sleeping object, or a dead object. This reaction, however, I have only seen in extremely disturbed and repressed patients.


Zeligs, M.A. (1961). The Psychology of Silence—Its Role in Transference, Countertransference and the Psychoanalytic Process. J. Amer. Psychoanal. Assn., 9:7-43

Let us first conjecture as to what a state of silence between any two (or more) human beings might signify. Obviously it could reflect many different psychic states and qualities of feeling.2 It might evidence agreement, disagreement, pleasure, displeasure, fear, anger, or tranquility. The silence could be a sign of contentment, mutual understanding, and compassion. Or it might indicate emptiness and complete lack of affect. Human silence can radiate warmth or cast a chill. At one moment it may be laudatory and accepting; in the next it can be cutting and contemptuous. Silence may express poise, smugness, snobbishness, taciturnity, or humility. Silence may mean yes or no. It may be giving or receiving, object-directed or narcissistic. Silence may be the sign of defeat or the mark of mastery. When life-and-death situations are
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2 Because of its ubiquity, silence has been thought about in many frames of reference. Poets, dramatists, and philosophers have loosely used the concept "silence" metaphorically and allegorically to symbolize death, eternity, truth, wisdom, strength, etc. Literary references to silence are frequent in the classics from all periods of history...
3 It is interesting that the aphorism, "Silence is golden, " represents what is left of the complete saying, "Speech is silvern, but silence is golden, " the part about speech having since dropped out of popular usage, historically attesting to the transitoriness of speech as compared to the permanence of silence. This derives from an ancient proverb written in Aramaic which first appeared in the Talmud Megillah and Midrash Rabba Esther (Chapter 6) in relation to prayer, as follows: "If a word is worth one selah, silence is worth two. (Silence invokes Thy praise.)"... The later Hebrew equivalent then became, "If a word be worth one shekel, silence is worth two, " pointing to the material advantage of keeping one's own counsel...
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being sweated through there is little occasion for words.3 Silence may be discreet or indiscreet. A tactful silence serves to prevent the expression of inappropriate thoughts and feelings. The art of being tactful combines the skilled use of silence in verbalized as well as nonverbalized action. Thus there is a hidden component of silence in every verbalization. When complete silence is inappropriate or impossible, a gesture, grimace, or mimetic expression serves as a compromise between verbal and nonverbal communication.

I'd love to hear about people's experiences with silence, so please comment.