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.

Thursday, October 23, 2014

Let's Talk about the ACA

I got a lot of responses to my recent post, Reinvention. I have to say, I was really touched by the concern people expressed, and I appreciate the suggestions for augmenting my soon-to-be-depleted income. I want to assure everyone that I am not on the verge of starvation.

One of the commenters focused on the Affordable Care Act (ACA), or Obamacare, and remarked, correctly, that not all the problems with healthcare can be blamed on the ACA. There was also a question of whether or not any of the NY exchanges covers out of network providers, because apparently, there's at least one that does in Massachusetts. Well, I checked, and there is no out of network coverage in the NY Exchange, except for immediate, emergent care.

Back in January, The Carlat Report published an article entitled, An Ethical Perspective on the Affordable Care Act, which I wrote. The contract I signed with them indicates that once 6 months has passed since the publication, I'm allowed to publish or use it myself, and since it's been that long, I thought I'd includea version of it here:

An Ethical Perspective on the Affordable Care Act

The Patient Protection and Affordable Care Act (PPACA), commonly referred to as the “ACA” or “Obamacare”, was signed into law on March 23, 2010. It’s mission: to secure health care for all US citizens, irrespective of age, gender, race, medical history, or socioeconomic status. This article will present a brief review of the ACA, and then discuss its ethical considerations, especially as they pertain to psychiatry.

First, An Ethics Refresher:

There are generally considered to be four principles of medical ethics:
Autonomy, which implies respect for a patient’s ability to make decisions for himself or herself; Justice, which allows for equal treatment of all, including fair allocation of scarce resources; Beneficence, or acting for the good of the patient; and Non-Maleficence which is the principle of primum non nocere, first, do no harm.

Ideally, any interaction with or treatment of a patient obeys all four principles, but in reality this is often not possible. For instance, the tension between autonomy and beneficence comes into question when determining patient capacity.

Provisions of the ACA are set to take effect by 2020, and generally fall into two categories: increasing access to healthcare (by mandating insurance coverage), and improving the quality and efficiency of health care delivery. Table 1 lists all the provisions scheduled through 2015, divided roughly into these two categories.

For the most part, potential ethical dilemmas for psychiatrists will occur in the quality and efficiency improvement category. Particular areas of concern are new innovations to improve quality and bring down costs, integrated health systems, linking payments to quality outcomes, payment bundling, and paying physicians based on value rather than outcome.

The Collaborative Care Model:

The Collaborative Care Model, developed by Wayne Katon, M.D., and Jürgen Unützer, M.D., at The University of Washington, is a type of integrated health system. Its implementation highlights many of the ethical pitfalls of the ACA, particularly as they pertain to psychiatrists.  In this model, primary care clinic patients are screened for psychiatric illness using simple rating scales. If the screen is positive, they are referred to a care manager, usually a MSW or other behavioral health provider, who oversees their psychiatric care. The care manager is, in turn, supervised by a psychiatrist, who reviews cases at regular intervals, but does not see the patients, except under unusual circumstances. Patient progress is measured by rating scales, until clinical goals are achieved. And providers are reimbursed based on clinical outcomes. (Link)

There have been some reports of success with this model. A study by Katon, et. al examined 214 participants with poorly controlled diabetes, coronary heart disease, or both and coexisting depression, randomized to usual care or collaborative care management by a medically supervised nurse. The intervention combined support for self-care using motivational and encouraging coaching, with pharmacotherapy, either citalopram or buproprion. At 12 months, patients in the intervention group had significantly greater overall improvement compared to controls. There was a significant difference in scores on the SCL-20 depression scale alone, but non-significant differences in the other individual outcome measures (HgbA1C, LDL, systolic BP).

The collaborative care model raises numerous ethical questions. It provides access to psychiatric care to many more patients than could be seen individually by psychiatrists, particularly in remote rural areas, thus allowing for the just distribution of scarce resources. At the same time, beneficence, and even non-maleficence, need to be considered, because care is being provided by people with limited training-in the Katon study, nurses attended a 2 day training course on depression management and behavioral strategies. And in a 2006 meta-analysis of collaborative care for depression, Gilbody, et. al found that, “...effect size was directly related to ...the professional background and method of supervision of case managers.”

In addition, types of treatment may be limited to medication, and follow-up to screening questionnaires, often conducted via telephone. 

What are the ethical implications of overseeing care for many patients who will never be interviewed in person? As a psychiatrist, would you be comfortable signing off on such care?
There is the question of putting an additional burden on primary care providers.
And there is the broader question of wasting resources by not utilizing the psychiatrist’s hard-earned skills. Which psychiatrists will find this work appealing, and will the model influence which medical students chose to pursue careers in psychiatry?

Other models of integrated care exist, such as the Collaborative Medicine and Behavioral Health (CoMeBeh) project at the University of Iowa, in which primary care is provided by physicians rotating through the psychiatry clinic, rather than the other way around. This excellent model is, unfortunately, limited by the fact that it targets a smaller population than the Katon model—those patients already in psychiatric care.

Value vs. Volume:

There are several innovations of the ACA which are intended to encourage not only better quality care, but better quality care at equal or lesser cost. In other words, greater value. 

The motivation for this idea seems clear. It acknowledges that a high volume of patients does not allow for much individual time or attention, so it attempts to incentivize physicians to provide better quality care for each patient.
Given that a goal of the ACA is to ensure coverage for all, it is paradoxical to expect doctors to spend more time with and provide better care for each patient, and to simultaneously reduce cost, when there are more patients to be cared for. But even assuming it is possible to get more for less, how does one go about implementing these innovations? How is value measured? And what ethical quagmires does one encounter in the process? 


The Physician Quality Reporting System (PQRS) was designed by the Centers for Medicare and Medicaid Services (CMS) as a way to improve the quality of care of Medicare beneficiaries by tracking practice patterns and providing incentive payments. It was implemented on a voluntary basis in 2007, for Medicare Part B Fee For Service (FFS) beneficiaries. But beginning in 2015, there will be payment adjustments for Medicare providers who do not satisfactorily report data. 

The PQRS is ponderous. Providers can report via one of five methods, some of which require a vendor. Beginning in 2014, providers are required to report at least 9 measures within at least 3 domains (e.g. Patient Safety, Person and Caregiver-Centered Experience and Outcomes, Communication and Care Coordination, Effective Clinical Care, Community/Population Health, Efficiency and Cost Reduction), at a certain frequency. 

One example of a measure pertinent to psychiatry is PQRS #9, Anti-depressant Medication Management: 

Percentage of patients 18 years of age and older who were diagnosed with major depression, and who remained on antidepressant medication treatment. Two rates are reported
Effective Acute Phase Treatment: Percentage of patients who remained on an antidepressant medication for at least 84 days (12 weeks) 
Effective Continuation Phase Treatment: Percentage of patients who remained on an antidepressant medication for at least 180 days (6 months) 

Clearly, this "measure of quality" has nothing to do with how well the patient is doing, and everything to do with coming up with something that can be easily measured-how long the patient has been taking medication. What if the patient is responding poorly, or taking an ineffective dose, or should be tapered off meds? Is that an example of "ineffective treatment"?

Similarly, “value-based purchasing holds providers of health care accountable for both cost and quality of care... [It involves]: measuring and reporting comparative performance; paying providers differentially based on performance; and designing health benefit strategies and incentives to encourage individuals to select high value services and providers and better manage their own health and health care.”
But how is performance determined, and will the patient's role be considered in this determination? Patients sometimes make poor choices. Should the physician’s income be adversely affected by those choices? Will doctors “cherry-pick” patients they think will be “good”? And is the patient’s autonomy diminished if the doctor is held responsible for his or her decisions?

Accountable Care Organizations (ACO’s) are groups of doctors, hospitals, and other providers who have agreed to work together to improve care and reduce costs. ACO’s that successfully demonstrate quality care and reduced costs “share in the savings” they create for Medicare. In addition, selected ACO’s can participate in the advance payment model , which provides upfront and monthly payments that can be invested in the ACO infrastructure. 

Ethical considerations for all the value measurement provisions include who is being served by these measures of value, and whether they truly measure value, or simply take up time and energy better spent with patients.

The Bundled Payments for Care Initiative involves paying a lump sum, rather than individually, for an “episode of care”. For example, if a patient is admitted for a course of ECT, rather than separately reimbursing the hospital, anesthesiologist, and psychiatrist who performs the ECT, all three will be reimbursed in one lump sum, presumably to be divided in a mutually agreed upon way. The intention seems to be to encourage collaboration between providers, and limiting of costs and overhead. But the effect may be limiting who is willing to participate, and "turfing" of work.

Coverage vs. Care:

Leaving aside questions about quality and efficiency, the ACA’s goal of health coverage for all presents its own ethical dilemma.  An expectation of medical care goes along with insurance coverage, but there is a discrepancy between the number of patients seeking treatment that will be paid for by their insurance, and the number of practitioners who will accept their insurance. In this respect, psychiatrists in private practice are in an unusual position. A study by Bishop et. al, published in JAMA Psychiatry Online on December 11, 2013, notes that psychiatrists are significantly less likely than physicians in other specialties to accept private noncapitated insurance (55.3% v. 88.7%, respectively, p<.001), Medicare (54.8% v. 86.1%, p<.001), and Medicaid (43.1% v. 73.0%, p<.001). 

The reasons for the discrepancy are unclear. One possibility suggested by the article is that while reimbursement rates for office-based psychiatric treatment are similar to those for office-based medical evaluation/management, psychiatrists don’t see as many patients per day as physicians from other specialties, resulting in less income for those who accept insurance. 
Another possibility is the fact that there are more psychiatrists than doctors from other specialties in solo practice (60.1% v. 33.1%), and solo practices require less infrastructure than larger practices, so there is less motivation to hire staff to interact with insurance companies, which is necessary to dispute claims and ensure reimbursement.
The article also cites a 14% decline in the number of graduates of psychiatry training programs between 2000 and 2008, and an aging workforce, as reasons the demand for psychiatrists exceeds the supply, and allows psychiatrists to not accept insurance. 

This is an ethical conundrum. Do we, as physicians, have a moral obligation to accept insurance, even if we lose income as a result? Or to provide care for patients who are unable to pay our full fees? Should we donate some percentage of our services, free of charge, to those who could not otherwise afford care? Or is it more ethical to treat patients who are free of the session limits and formulary restrictions that come with insurance coverage, even at greater financial cost to the patient? 

In regard to the doctor’s need to make a living, Freud writes, “It seems to me more respectable and ethically less objectionable to acknowledge one's actual claims and needs rather than...to act the part of the disinterested philanthropist—a position which one is not, in fact, able to fill, with the result that one is secretly aggrieved, or complains aloud, at the lack of consideration and the desire for exploitation evinced by ones patients.” (On Beginning the Treatment (Further Recommendations on the Technique of Psycho-Analysis I). The Standard Edition of the Complete Psychological Works of Sigmund Freud, Volume XII (1911-1913): The Case of Schreber, Papers on Technique and Other Works, Pp. 131-132

The ACA has taken on the challenge of guaranteeing affordable and quality health care for all Americans. This is a noble undertaking, with vast challenges, and unpredictable ramifications, including ethical dilemmas for doctors. What are the moral implications of refusing to accept insurance? Does that harm or help our patients? Is it possible to provide better care at lesser expense, and will we or our patients suffer as a consequence? How do we know what constitutes better care, and are measures of care helpful, or simply time-consuming? Is it more ethical to provide full care for the few, or limited care for the many? Perhaps we can view these dilemmas as opportunities to re-examine our values, and the reasons we chose to become doctors in the first place.

1 comment:

  1. Thanks for reading my comment so carefully. The insurer in MA is Harvard Pilgrim which uses United for Behavioral Health. (That's the shittiest insurance ever, I'm told. There was even an article in the Globe about their denial of mental health coverage.) It may be the only one though, and MA regulators are supportive of limited network plans.