Contined from: Systemic Failure of American Healthcare Part I
A perfect storm collapsed our healthcare system as a whole, including mental health. Where are we going wrong? And how can we make it right?
Diagnosing and prescribing for profit becomes a trend among major health insurers.
Problem 1: Societal and economic reinforcement of dangerous healthcare practices.
Let’s pretend as a mental health therapist, that I got paid to make more diagnoses per patient. If I could find 5 major mental health disorders versus 2, I would retain higher profits from insurance reimbursement. Is that how finances work in the mental health field? No. It doesn’t matter if I label someone with bipolar disorder or depression, anxiety, trauma, adjustment disorder, or any other identification from the DSM-V. We are reimbursed for the time and intensity of treatment as well as our training. A crisis is billed differently than a family intervention, for example. An EMDR or CSAT therapist charges more because these trainings run into the tens of thousands of dollars and are rarely covered by scholarships.
If there were a larger reimbursement for diagnosing a patient with post-traumatic stress disorder (PTSD) versus bipolar disorder, then there would likely be an upward trend in people diagnosed with PTSD. For example, practitioners could reason that depression is a part of PTSD, and have certain symptoms of depression molded to sound like PTSD. This could occur as an unconscious tendency to link these together in a well-meaning practitioner, or as a concerted deliberate manipulation by another with poor integrity. In fact, the two often overlap in symptoms (Flory JD, Yehuda, 2015). The point here is that setting up a system to provide financial rewards for one diagnosis versus another changes the objectivity of diagnosing and adversely affects patient or client care. Reasoning is easy, and a practitioner could find more disorders if they chose to look. Mislabeling is also easy if there is no motivation to make the correct one.
Although the vast majority of providers are well-meaning and trying to do the right thing, large-scale analysis of the data shows trends toward diagnoses that provide more reimbursement. Exactly where this trend stems from, whether it be insurance companies(payors), healthcare organizations, individual providers, or some combination, is not entirely clear. The New York Times’s 2022 article on major healthcare fraud discusses large insurers who were accused of corruption for mining patient records for diseases, and adding new diagnoses, in order to get reimbursed.
There are laws against fraud. The tracking and mitigation of risk for every patient and every claim seen on a daily basis is impossible; but there is the potential to improve with tools such as artificial intelligence (Gaurav, D. and Blaschka, 2017). Billions of provider visits daily assigned to understaffed government auditors leave a large gap for malpractice. Patients are also rarely educated to otherwise know when they have been led astray by being labeled with an unnecessary or redundant diagnosis, which could lead to additional out-of-pocket charges, stigmatization and labeling, and even patient harm. These may not be caught and corrected until a whistleblower reports malpractice or a tragedy like a death occurs.
Fraud and abuse taint the healthcare system – caused by several bad actors, societal conditioning to avoid painful realities, and policies that reinforce corrupt practices.
So is it just a private insurance issue?
The International Journal of Health Policy Management estimates 10% of total healthcare expenditures are spent on fraudulent and abusive practices (2016).
- Police officers and firefighters are more likely to commit suicide than die in the line of duty.
- 85% of first responders have experienced symptoms related to mental health conditions.
- Depression and PTSD are up to 5 times more common in first responders.
SAMHSA reports 300 police officers commit suicide yearly. How we respond to these individuals that are the first on the scene of crises when they experience their own crises matters.
Isn’t this reported? What about the whistleblowers?
American society also has a history of shitting on whistleblowers, which has the result of compelling most to remain silent and move on to other organizations. Why go through the pain and trauma of outing a scandal when the blowback is horrendous. Paula Pedene and Kuauhtemoc Rodriguez experienced this directly. They did the right thing, and they were punished with threatened livelihoods.
Kuauhtemoc Rodriguez, like other informers, experienced direct retaliation and harassment for reporting the cover-ups at the Veterans US Department of Veterans Affairs (VA). His statement reflects this reality, “As an Iraq veteran, it makes me feel like dirt that bureaucratic civilians who’ve never served this country are abusing vets like me, and killing vets who are defenseless because they’re ill.” He worked as a scheduling manager for the Phoenix VA’s specialty care. “They know the price of freedom and the VA abuses that, and benefits off the backs of veterans.”
This does not happen often. When it does, little changes. And, the VA isn’t the only institution. It happens in many.
Note: Little changed as of 2017 in the VA operations, as reported in this same article in article in NBC News.
215 Soldiers died as a result of the VA’s faked waitlists which were purported to be an attempt to better the numbers of soldiers served. The bottom line is that hundreds of veterans who sacrificed for our country lost their lives as a result of execs in that system working to “fix” their metrics while ignoring the human cost.
At the Phoenix VA, it took soldiers blowing their brains out in the parking lot in order to gain relevant attention.
The issues exposed within the VA open a new level of healthcare deceit and abuse.
This can of worms sheds light on the dark practice of number manipulation, silencing, avoidance, and cost-hoarding practices.
Richard Lyons highlights problems, citing the VA takes an excruciatingly long period to hire qualified candidates and pays them up to 20% less than the current rate in the private market. I feel he really hits the mark with this quote: “It indicates the VA is paying psychiatrists and psychologists and other mental health professionals 20% less than the going rate in the private market and it takes 6-8 months to get hired.”
I, for example, cannot work for the VA because the cost of living outweighs the salary and their hiring practices eliminates my candidacy. Never mind the fact that I’m a licensed mental health therapist with extensive training in effective and safe trauma resolution modalities. They only hire social workers, not mental health therapists; and working as a social worker for 20% lower compensation won’t make ends meet to afford a 2-bedroom home.
But having a soldier commit suicide in the parking lot after being denied crisis care seems incredibly sensible (sarcasm).
Note: I take veterans on pro-bono or at incredibly reduced rates in my private practice to counteract this loop and to give back. I also work with Operation Resource Arizona to help veterans myself or get them to where they need to be.
Problem 2: A Disconnected but Enmeshed System
Unless you use an integrated healthcare system, your providers probably do not talk to each other.
They should, but do they actually?
Non-communication between healthcare providers, including mental and physical healthcare clinicians, leaves large gaps, which means lots of room for errors, omissions, duplications, and safety issues. Some organizations have common electronic medical record systems (EMRs) where they can pull up patient charts between the organizations, but this is not the norm.
For the backstory: the legal process of sharing information between practitioners in segregated healthcare systems begins by requesting permission from the patient, explaining the necessity, then acquiring a signature for the patient to acknowledge the ability to share information, phoning the other practitioner, then coordinating a time to talk with that clinician. This process in its entirety can take weeks, depending on providers.
Without communication, your health care overlaps and is at risk for conflicting treatment applications (ie. doubled prescriptions or prescription of contraindicated medications), overlooked conditions, missed diagnoses, or interventions that do more harm than good. You are ultimately left to coordinate a healthcare team where you serve as the central communication provider. This is a big problem because:
1. Most people do not have the education or background in physical(allopathic) medicine or mental health to do this safely and effectively.
2. There are those that have the inability to discern which pieces of information are important or to convey that information concisely. In alexithymia, for example, autistics cannot put words to their feelings. Autism gets missed much of the time as their symptoms are honed in on separately and practitioners miss the big picture.
Among other problems, this lack of accurate and efficient communication can lead to actively harmful problems such as misdiagnosis. Misdiagnoses occur in all healthcare and a small percentage is unavoidable due to misinformation or human error. However, misdiagnoses occurring from a lack of accurate and efficient communication between providers certainly fall into the avoidable category.
In addition to the obvious treatment, healing, and safety consequences of misdiagnosis, an incorrect treatment approach can also further traumatize the person through gaslighting or victim blaming.
A common misdiagnosis in my field is differentiating between symptoms of PTSD, depression, anxiety, or bipolar disorder. Several of these diagnoses can mimic each other in certain ways, and the clinician needs to expend extra effort to obtain an accurate diagnosis as the course of treatment for each differs substantially. For example, PsychCentral outlines how the treatment for bipolar and PTSD differ. The approaches for bipolar disorder have more dependence on medication and coping skills whereas trauma resolution is the focus for PTSD.
Another example of a common misdiagnosis is that of autism. If a patient reports depression, anxiety, ADHD, and in combination with or without co-occurring addiction, trauma, and bipolar disorder or borderline personality disorder, I screen for autism. The number of people that had autism versus the other diagnoses is astounding. Autistics are twice as susceptible to addiction as neurotypicals (non-autistics) (Szalavitz, 2017). Other studies suggest that 20% of autistics have undiagnosed autism (The Harvard Gazette, 2022).
Problem 3: Other Contributing Factors
Less workers are entering behavioral health. A perfect storm of factors deters potential workers from entering into the behavioral health field (US Government Accountability Office, 2022).
The cost of education prevents or deters students from attending college. In 2003-2023, the average cost of year for college increased by 141-175%. These statistics vary per private, state, or out-of-state status for students, and per state. For comparison, the rates of tuition increase from 1969-1999 averaged 3.6%.
You can reduce educational costs by working for a company that helps with the funding like Starbucks or Amazon or attending one of the few select universities like those in New York that offer free college tuition. There are always obstacles of their own in those situations. You won’t always get hired, may not qualify, stay hired depending on company layoffs or the economy, or be able to work full-time while attending school. Scholarships can help. However, these are usually little helpful when compared to a $160,000 4-year tuition bill plus living expenses. Then, there’s graduate school, another 3-4 years after the initial 4 years to gain a masters or doctorate degree. That puts your tuition over the $200,000 mark typically. And, there are not enough scholarships to cover every student, for every penny.
As for the loan forgiveness program, few have had theirs discharged after working decades in non-profits. As of January 2021, 32 borrowers received income-driven repayment student loan forgiveness.
It’s nonsensical when you do the math:
For those near me:
The poverty-defined salary cutoff in Montana in a family of 5 is $35,140. Those that work in community and social services average around $50,000 per year. Add the cost of over $100,000 college loan payment for tuition fees up to graduate school, with payments more than a house mortgage, inflated living expenses, the costs outweigh benefits. The Massachusettes Institute of Technology (MIT) Living Wage Estimator estimates the required living wage per family before taxes for a house with 3 children in Montana is over $127,000 per family.
A 3-bedroom house rents on average for $2,245 in Missoula, Montana. This consumes the majority of a monthly income for those working in fields with a masters degree in social services and healthcare.
There are other factors, such as that deter therapists from working in the public sector, like overloading of casework, burnout, low job satisfaction, exhaustion, and underpay. The pain and low insurance reimbursement rates with questionable coverage for healthcare from insurance companies puts to death any desire to work with insurance companies. I will save that for another story.
In short, our system as a whole, in and outside of healthcare, is not set up in any way to promote mental health support for its citizens, in the public or private sectors or economy as a whole. There is still much work to do and many areas we need to focus on, starting with prizing people over profit. Put more policies in place to support the improved access of mental healthcare to the public and private sectors, manage fraud better, eliminate policies that encourage corrupt practices, and make education affordable and desireable. The common denominator of money continues to be the biggest obstacle. Sadly, it will take more tragedies for anyone to make minor improvements, and our system will continue to change at an excruciatingly slow pace.
- Flory JD, Yehuda R. Comorbidity between post-traumatic stress disorder and major depressive disorder: alternative explanations and treatment considerations. Dialogues Clin Neurosci. 2015 Jun;17(2):141-50. doi: 10.31887/DCNS.2015.17.2/jflory. PMID: 26246789; PMCID: PMC4518698.
- International Society for Pharmacoeconomics and Outcomes. “US Healthcare System Overview-Background.” (2023). Retrieved from: ispor.org/heor-resources/more-heor-resources/us-healthcare-system-overview/us-healthcare-system-overview-background-page-1
- Khawar, Ali. Reflecting on how the Affordable Care Act Changed Health Coverage; 2022. Accessed from: https://blog.dol.gov/2022/03/23/reflecting-on-how-the-affordable-care-act-changed-health-coverage
- Jamison DT, Breman JG, Measham AR, et al., editors. Disease Control Priorities in Developing Countries. 2nd edition. Washington (DC): The International Bank for Reconstruction and Development / The World Bank; 2006. Chapter 1. Available from: https://www.ncbi.nlm.nih.gov/books/NBK11754/ Co-published by Oxford University Press, New York.
- Hoffman, K. Addiction and Autism. March 23, 2023; https://www.addictionhelp.com/addiction/autism/
- Szalavitz, M. March 2, 2017. The Hidden Link Between Autism and Addiction. Accessed from: https://www.theatlantic.com/health/archive/2017/03/autism-and-addiction/518289/
- Gaurav, D. and Blaschka, T. “Diagnosis Fraud: How Data Science Can Diagnose Healthcare Fraud and Identify Dirty Doctors.” December 16, 2019. Accessed from: https://www.dataversity.net/diagnosis-fraud-how-data-science-can-diagnose-healthcare-fraud-and-identify-dirty-doctors/
- Washington Post. “Declining life expectancy in the U.S.” 2023. Accessed from: https://www.washingtonpost.com/podcasts/post-live/declining-life-expectancy-in-the-us/
- Abelson, R and Sanger-Katz, M. “The Cash Monster Was Insatiable’: How Insurers Exploited Medicare for Billions.” October 8, 2022. Retrieved from: https://www.nytimes.com/2022/10/08/upshot/medicare-advantage-fraud-allegations.html
- Kilbourne AM, Beck K, Spaeth-Rublee B, Ramanuj P, O’Brien RW, Tomoyasu N, Pincus HA. Measuring and improving the quality of mental health care: a global perspective. World Psychiatry. 2018 Feb;17(1):30-38. doi: 10.1002/wps.20482. PMID: 29352529; PMCID: PMC5775149.
- BBC. How many US mass shootings have there been in 2023? April 17, 2023. Accessed from: https://www.bbc.com/news/world-us-canada-41488081
- Richards, T. “Whistleblowers Claim Retaliation for Revealing VA Horrors.” January 29, 2017. Accessed from: https://www.nbcnews.com/news/us-news/whistleblowers-claim-retaliation-revealing-va-horrors-n707996
- Martinez, M. “Families sue Phoenix VA for $55M after 2 veterans die who sought mental health treatment.” Fox News. December 6, 2019. Accessed from: https://www.fox10phoenix.com/news/families-sue-phoenix-va-for-55m-after-2-veterans-die-who-sought-mental-health-treatment
- Joudaki H, Rashidian A, Minaei-Bidgoli B, Mahmoodi M, Geraili B, Nasiri M, Arab M. Improving Fraud and Abuse Detection in General Physician Claims: A Data Mining Study. Int J Health Policy Manag. 2015 Nov 10;5(3):165-72. doi: 10.15171/ijhpm.2015.196. PMID: 26927587; PMCID: PMC4770922.
- Glasmeier, A. Living Wage Calculation for Missoula County, Montana. Massachusettes Institute of Technology. Accessed from: https://livingwage.mit.edu/counties/30063
- Morse G, Salyers MP, Rollins AL, Monroe-DeVita M, Pfahler C. Burnout in mental health services: a review of the problem and its remediation. Adm Policy Ment Health. 2012 Sep;39(5):341-52. doi: 10.1007/s10488-011-0352-1. PMID: 21533847; PMCID: PMC3156844.
- “Behavioral Health:Available Workforce Information and Federal Actions to Help Recruit and Retain Providers.” US Government Accountability Office. October 27, 2022. Accessed from: https://www.gao.gov/products/gao-23-105250