Download Single-Payer and the Crisis in Mental Health Care

SINGLE-PAYER AND
THE CRISIS IN MENTAL
HEALTH CARE
Stephen Kemble, MD
for
PNHP Annual Meeting
New Orleans, November 15, 2014
Disclosure
• No financial conflicts of interest to disclose.
• I receive no money whatsoever for any of my
involvement in health care reform and health
policy activities.
Three Systems for Mental Health Care
• 1970’s: Cambridge Hospital
• Community psychiatry for Medicaid
• 1980’s: Hawaii’s FFS Medicaid
• Weak public system (clinics, state hospital)
• Widespread private sector participation
• Hawaii’s Medicaid Managed Care
• 1990’s: Local not-for-profit Medicaid managed care for
GA and AFDC
• 2009: For-profit Medicaid Managed care for ABD
Medicaid
Community Psychiatry at Cambridge Hospital
• Dept. of Psychiatry - contracted for all Medicaid
mental health for Cambridge and Somerville
• NO competing managed care plans
• Comprehensive services and programs
• Reach out to meet needs of pts and community
• Interdisciplinary team care, good coordination
• High morale, low administrative cost, good care
• No central management of care by insurance plans
or government
• BUT, two-tier system
Hawaii FFS Medicaid (prior to 1994)
• Weak Public MH System
• Dept. of Health clinics run by AMHD/CAMHD
• State Hospital – attempted closure, became forensic only
• Ranked 51st in US, Felix Consent Decree
• Widespread participation by private sector psychiatrists
• Most built practices with Medicaid
• Psychiatric units in general hospitals
• Specialized SMI and substance abuse programs
• Generally good access in private sector
• Generally adequate supply of psychiatrists
• Relative shortages on neighbor islands
• BUT, 1st for-profit psych hospital in late 1980’s
Hawaii’s Medicaid Managed Care
Experience
• Converted FFS Medicaid to MCOs - 1994, 2009
• Increased administrative hassles (and cost)
• Declining MD participation
• Worsening access problems
• Accelerated cost increase – 2.7% > US average
• Worst for mental illness – 4 yr after Medicaid
managed care, > half of psychiatrists dropped
out, MH ER and hospital costs increased 30%!!
Kaiser State Health Facts FY ‘90-’10, Hawaii Health Information Corp 06-26-13
MH Managed Care Outcomes
• Managed care worst for psychiatry
• 100% Prior Authorizations
• Restricted formularies, extensive PA’s
• Cutting off GA benefits for missed appointments
• Disrupting long-term doctor-patient relationships
• Psychiatrists restricted to med management only
• Demoralized work force
• Declining interest in psychiatry as a specialty
• Rapid move to self-pay only, concierge practices
• Drastic reduction in access to care
• SMI patients
• Medicaid patients generally
Motivating Doctors to Improve Care
• Intrinsic motivation:
• Helping people
• Intellectual challenge, expanding knowledge
• Professional ethics
• Extrinsic Motivation:
• Financial incentives and penalties – “carrots and sticks”
• Central management by MBAs
• Manage what you measure –
• Metrics
• Quality scores
• Pay-for-performance
Daniel Pink – Drive:
The surprising Truth About What Motivates Us
CARROTS AND STICKS: The Seven Deadly
Flaws
1. They can extinguish intrinsic motivation.
2. They can diminish performance.
3. They can crush creativity.
4. They can crowd out good behavior.
5. They can encourage cheating, shortcuts, and unethical
behavior.
6. They can become addictive.
7. They can foster short-term thinking.
Daniel Pink – Drive:
Fostering Motivation:
1. Autonomy (practice within scope)
2. Excellence (continuous improvement)
3. Pursuit of a goal larger than oneself.
Pink, Thomas H. Drive: The surprising Truth About What
Motivates Us. Riverhead Books, 2014
Don Berwick – The Toxicity of Pay-forPerformance
“Despite their superficial logic, systems of merit pay or pay
for performance have features that are toxic to systemic
improvement. Contingent rewards doled out by supervisors
cause decreased focus on customer needs, loss of
accurate information about defects and improvement
opportunities, avoidance of stretch goals, and decreased
innovation. They may also erode teamwork. Pay for
performance may mark a naive understanding of the
complexity of human motivation.”
• Berwick DM. The Toxicity of Pay-for-Performance. Quality Management in
Health Care, 1995, 4(1), 27-33.
Single-Payer Cost Control
Assure access to cost-effective
care for all
2. Simplify, streamline administration
3. Use administrative savings to
reduce prices
1.
• Hospitals - global budgeting
• Doctors – negotiated fees, simplified admin,
support for quality improvement
• Drugs and medical equipment - negotiated
prices, bulk purchasing
Mental Health Care under Single-Payer
Physician Pay:
• Same for all patients
• regardless of socio-economic status or source of funding
• Make payment system administratively simple
• No administrative barrier to practice in rural or under-served
areas
• Incentive-neutral pay
• Salary, or fee-for-time
• adjusted for training and practice costs
• Not tied to complex coding, E&M, RBRVS
• Higher pay for child psychiatry services
• More training
• More time to deal with family, schools, etc.
Mental Health Care under Single-Payer
Physician-Driven Management of Care
• No corporate Managed Care organizations
• Expanded formulary, minimize PA’s
• Use bulk purchasing, not formulary restrictions, to
control drug prices
• Quality Improvement
• Local projects, developed and controlled by physicians
and other health professionals involved in care delivery
• Rely on intrinsic motivation
• No pay-for-performance incentives
Mental Health Care under Single-Payer
Specialized Services for SMI and
Substance Abuse:
• Set up as “public utilities”
• Available to entire community based
on patient need
• Publicly funded, global budgets
• Interdisciplinary, team-based care
Mental Health Care under Single-Payer
Specialized SMI/SA Services:
• Crisis intervention, hotlines, crisis shelters
• Residential & day programs, including for dual
diagnosis
• Psychosocial rehab
• Substance Abuse - residential, intensive out-patient
• Community consultation
• Community outreach & home visit capabilities
• Coordinated with primary psychiatrist, psychologist,
or PCP
Mental Health Care under Single-Payer
Training:
• Focused on treatment of SMI population
• Interdisciplinary care
• Strong substance abuse component
• Ensure newly trained psychiatrists are comfortable
with patient populations with greatest need
• Psychiatrists more likely to continue with these
populations when in practice
• Integrative care – psychiatrists collaborating with
primary care for management of psychiatric patients
Fighting Medicaid Managed Care in Hawaii
• Op-Eds in Honolulu Papers
• “For Health Care, Single-Payer System is Best” - Jan 23, 2009
• “Competition in Health Care Problematic” – Nov 15, 2009
• “Consolidating all Medicaid programs would save money and
•
•
•
•
•
expand access” – July 27, 2011
“State should end Medicaid managed-care model” – April 21, 2013
“More health care regulations mean more middlemen, fewer
doctors” – Nov 27, 2013
“Medicaid Red Tape Crippling Good Health Care” - April 6, 2014
“Healthcare Pay-For-Performance Folly” July 7, 2014
“Let’s Reduce Administrative Burdens in Health Care” -Nov 2014
• Testimony on Medicaid Section 1115 Waivers
• Hawaii Health Authority
Everybody In, Nobody Out
If • Everyone had the same comprehensive coverage
• It were administratively simple to practice any specialty in
any location
• MD pay were equitable, based on training + practice cost
• MD pay were not skewed toward procedures or by payfor-documentation and pay-for-performance incentives,
Then • Many more MD’s would choose primary care and
psychiatry again
• Patients would have access to care based on need
• US health spending would be similar to other developed
countries