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.

It's All in the Spin

Another email from the APA today, oh joy:

CBT More Efficacious Than Other Psychological Interventions for Positive Symptoms of Psychosis.

This was based on the article: Psychological Interventions for Psychosis: A Meta-Analysis of Comparative Outcome Studies, published February 14th on AJP in Advance.

CBT was compared with supportive counseling, social skills training, psycho-education, cognitive remediation and befriending in 48 trials.

Results  Cognitive-behavioral therapy (CBT) was significantly more efficacious than other interventions pooled in reducing positive symptoms (g=0.16). This finding was robust in all sensitivity analyses for risk of bias but lost significance in sensitivity analyses for researcher allegiance, which suffered from low power. Social skills training was significantly more efficacious in reducing negative symptoms (g=0.27). This finding was robust in sensitivity analyses for risk of bias and researcher allegiance. Significant findings for CBT, social skills training, and cognitive remediation for overall symptoms were not robust after sensitivity analyses. CBT was significantly more efficacious when compared directly with befriending for overall symptoms (g=0.42) and supportive counseling for positive symptoms (g=0.23).

The APA seems rather pleased with itself about this result. The email even linked to a news article, CBT Addresses Most-Debilitating Symptoms in Chronic Schizophrenia.

A new cognitive-behavior therapeutic strategy [Recovery Oriented Cognitive Therapy (CT-R)] is helping patients overcome major obstacles to their recovery, especially the negative symptoms...that are considered to be the most intransigent and disabling for patients with schizophrenia. The strategy has been implemented throughout the Philadelphia public mental health system and in Georgia

You'd think they'd at least cross check their own links. CT-R is especially helpful with negative symptoms, but the meta-analysis demonstrated that social skills training was significantly more efficacious than CBT in reducing negative symptoms.

The email caught my eye because I had just finished reading this month's Carlat Report, in which there was an article entitled, "CBT for Schizophrenia: Is Talk Cheap?", which, in turn, references, "Cognitive-behavioural therapy for the symptoms of schizophrenia: systematic review and meta-analysis with examination of potential bias," published in the British Journal of Psychiatry.

THIS study looked at 50 trials of CBT for schizophrenia, and found that when raters were blinded to the type of treatment provided, effect size of CBT relative to placebo dropped from 0.62 in unblinded studies, to 0.15 in blinded studies, for overall symptoms. For positive symptoms, the drop was from 0.57 to 0.08. 
Pooled effect sizes were 0.33 for overall symptoms, 0.25 for positive symptoms, and 0.13 for negative symptoms. 
Not sure why they didn't describe the difference between unblinded and blinded studies for negative symptoms. Maybe because the pooled effect size was so low to begin with.

It's kind of like what I wrote about the APA excitement about the meeting in May. Pick some highlight, maybe Alan Alda, talk about how great the meeting will be, and ignore all the annoying little facts that might put a damper on things. 

Why Does this Bother Me?

I got an email today about the annual meeting of the APA, which is in NYC this year. I suppose I could attend, even though I terminated my membership in the APA a while ago. This was in the email:

APA 2014: Changing the Practice and Perception of Psychiatry

APA President Jeffrey Lieberman, M.D., is using the Psychiatric News Alert as a forum to reach APA members and other readers. This column was written by Dr. Lieberman and Philip Muskin, M.D., chair of the APA Scientific Program Committee. Please send your comments to pnupdate@psych.org.

Annually, thousands of mental health professionals descend on a major American city to participate in a three-ring circus of pedagogic activities that comprise the annual meeting of the American Psychiatric Association. This event is an academic smorgasbord of all information relevant to psychiatric medicine and mental health care. It provides one-stop shopping for clinicians who wish to avail themselves of the latest scientific developments and all the education needed to practice their craft. The annual meeting is the highlight of the year for U.S. psychiatry.

APA’s 167th Annual Meeting will take place May 3 to 7 in New York City and will be the epicenter for those who wish to learn of emerging knowledge and connect to leaders in the field of psychiatry. New York is a perfect place to host this year’s meeting, given the extraordinary and historic events of the past year, including the launch of DSM-5, the release of the final rule for the Mental Health Parity and Addiction Equity Act, further implementation of the Affordable Care Act, and the emotionally wrenching discussion of mental illness and violence in the media.

The theme of the 2014 annual meeting is aptly titled “Changing the Practice and Perception of Psychiatry,” reflecting the historic transformation in how our profession will be practiced, as well as perceived by our medical colleagues and the public at large. The Scientific Program Committee, chaired by Phil Muskin with Co-Chair Cam Carter, has produced an amazing program with a who’s who of luminaries scheduled to speak. The Opening Session will feature a “Dialogue on Science and the Media” that I will moderate between Nobel Laureate Eric Kandel and the acclaimed actor Alan Alda. The Convocation Lecture will be delivered by a major political figure who is leading major legislative initiatives in mental illness. Look for more information in a future issue. 

I happen to be a huge Alan Alda fan, and that alone is a draw. But my skin is just crawling, and I'm not sure why. 

Here's a link to the full text of above. Many of the sessions are organized into tracks, such as forensics, child/adolescent, ethics. There's a mentoring track for residents. and a track dedicated to military health care.

There's also an integrated care track:

The Integrated Care Track features interactive sessions applicable to every psychiatric physician in this current culture of health care reform and comprehensive patient-centered service. By participating in workshops led by experts like Lori Raney, M.D., you will learn practical skills to prepare for leadership roles of the psychiatrist within a collaborative care team. The CPT coding workshop, chaired by Ronald Burd, M.D., is another educational opportunity relevant to all due to changes in health care financing and reimbursement that occurred at the start of 2014.

"Leadership roles of the psychiatrist within a collaborative care team." This is a definite formicatory sentence. I wanna reply, "You mean, as opposed to psychiatric roles of the psychiatrist within a collaborative care team," because in a collaborative care model, the psychiatrist doesn't see patients, just supervises those who do, and signs off on the charts of these unexamined patients. And as Socrates said, "The unexamined patient is not worth treating." Or something like that. (I was gonna write, "not worth living", but that sounded way harsh.)

I think what bothers me about the meeting is everything that's left unsaid. There's all this, "Yay! DSM-5! Here's how to use it!" Rather than, "DSM-5, let's talk about the controversy". 

And there's, "Yay! RDoc! NIMH!!" as though we're already at an advanced stage of knowing how the brain produces psychiatric illness. 

"Yay! Psychopharm!" as though there are no questions about efficacy and safety, even with Paxil study 329 glaring in everyone's face. 

I also hate the phrase, "Patient Centered Care". 

As opposed to what? Kumquat-Centered Care?

And I'm irritated by the notion that the APA meeting presents, "all information relevant to psychiatric medicine and mental health care." Do they really think there's no valid perspective on psychiatry outside that of the APA?

I glanced at the program, and I was pleased to find a reasonable emphasis on psychotherapy, especially of the psychodynamic variety, and Kernberg and Fonagy will be there. And Kandel is always a welcome presence.

I'm not sure why I find the whole thing so icky, or why I expect anything to be different. I just remember being at the meeting in NYC 10 years ago, and the most impressive thing was all the pharmaceutical presentation areas. Maybe there won't be as many this year. And maybe they're trying to keep them out of the program. 

I found this paragraph on page 7:

Sunshine Act

Some of APA’s non-CME accredited events and some refreshments at APA events are sponsored by pharmaceutical or medical device companies. Participation in these events/ food offerings may be reportable under the Physician Payment in the Sunshine Act.

Just this one little blurb. Like, hey, that's not a herd of elephants we all see traipsing about the Javits Center.

I feel like there's some big issue being sidestepped. That the influence of industry is so integral that no one even bothers to talk about the conflicts of interest. I know there's a lot of excess hype about David Kupfer's ownership of Psychiatric Assessments, Inc., which provides assessment instruments to be used in conjunction with DSM-5 (Link), but it's as if the meeting just goes along its merry way, completely oblivious to Voldemort's shriveled, twisted soul lying under a bench.

As though psychiatry isn't a mess. 

It really bothers me.

Who Needs Who

Check out this article in Psychiatric News, if you haven't already. 

Jeffrey Lieberman, president of the APA, asks us to be nice to poor, little Big Pharma. 

He notes past problems, "including high drug prices, aggressive marketing practices and direct-to-consumer advertising, efforts to buy influence with physicians, and, perhaps most egregiously, the suppression of data on drugs’ dangerous side effects."

He goes on to say:

But let’s face it, they need us and we need them. We must recognize the important, beneficial role that drug companies have long played in all areas of medicine. While not minimizing problems, we simultaneously must remember how products have improved the quality of health care and quality of life in our society, and their funding has helped to advance research, public outreach, and training.

He finishes up with:

We now are moving forward with careful vigilance in ways that recognize the value of industry relationships. Under the auspices of the American Psychiatric Foundation (APF), interactions with industry are helping to restore important relationships. ...I believe that the rules and models for informational, educational, and research engagement can and should be developed and applied in ways that allow for our optimal engagement with companies. Doing so would not only help us learn from the mistakes of the past; it would help us improve the future for our profession and our patients. 

I agree with the fact that we need them. Unless we want to put all our patients on Lithium and St. John's Wart, the meds have to come from someplace. And I don't fault Big Pharma for trying to make a buck or two billion.

But I also agree with the fact that they need us. No prescribers, no sales. So why do we have to be nice to them? And why does the president of the APA have to ask us to do so?

Sorry if I'm skeptical, but:

GlaxoSmithKline has admitted that some of its senior Chinese executives broke the law in a £320m cash and sexual favours bribery scandal.

And:

Big pharma mobilising patients in battle over drugs trials data.

The veracity of this last one is a little controversial, I suspect because Big Pharma intervened (See Eye For Pharma).

The idea is that if pharmaceutical companies make their data transparent for review and interpretation by the world at large, like in RIAT, science may be compromised, and private patient information may be revealed. 

I guess the world at large doesn't understand science as well as pharmaceutical companies do. And oh yeah, data for subjects in drug trials are anonymous.

(Please check out 1boringoldman.com for a more extensive discussion of this controversy)

So, again, why is the APA on a kick to endorse Big Pharma?

To quote Danaerys Targaryen, "I am only a young girl, and know little of such matters."

But I wonder what the APA gets out of the endorsement.

According to Gary Greenberg, regarding the APA's financial picture:

Income from the drug industry, which amounted to more than $19 million in 2006, had shrunk to $11 million by 2009, and was projected to fall even more. Membership was dropping, off by nearly 15% from its highs, and with it income from dues and attendance fees. Journal advertising was off by 50% from its 2006 high of $10 million.

I looked up the APA's 2012 Treasurer's Report, and found the following charts:

What's a picture worth, again?