Shortly after I posted a two-part blog on this site back in February about New York’s just-approved Medicaid Health Homes, I got this crazy, ultimately grandiose idea to talk to the case managers and clients I had worked with for years as director of a New York City case management program. Most of them were still with the program and I believed we still had a good connection with one another. Given all the changes they would soon be subjected to, I thought it might be helpful if they got a view of the prospective impact of those changes from the perspective of an advocate and critic of the public mental health system.
This a story about what transpired. More importantly, it serves as the introduction to an update of New York’s Medicaid Health Homes, designed to serve as the primary service delivery system for approximately one million New Yorkers diagnosed as having one or more chronic ailments. These latter include individuals with serious mental illnesses, substance abuse disorders and chronic physical ailments, as well as individuals who require long-term care and those with developmental disabilities. Together, these several groups constitute the proverbial 10% that eat up 90% of New York’s Medicaid expenditures. Further, while the stated objective of the homes is to provide integrated, coordinated behavioral and primary health care to persons historically denied it, their other key objective, integral to the Affordable Care Act (ACA) and the New York’s own Medicaid reform effort, is to render that care cost-effective, i.e., to save tax payer dollars. I’ll talk at some length about that particular issue.
In any event, I was barred from addressing the staff as well as the clients who attend the program’s advisory committee meetings by top-level administrators of the agency I formerly worked for. Indeed, that was the explanation offered, that I was a former employee. Instead, I was invited to address the top-level administrators and middle managers who were responsible for overseeing the agency’s health home initiatives. As Tom Wolfe wrote, you can’t go home again, at least not when your ex-boss chairs your homecoming meeting. Everything – and I mean “everything” – I said was contested. Every point I tried to make engendered a struggle, not so much with the middle managers, who remained largely silent throughout, but with their superiors. So it goes in very hierarchical organizations. By meeting’s end, I had concluded that I had been awfully ingenuous to think I could have a free-flowing give and take with agency executives. As I pointed out during the meeting, they had to be optimistic about what they were doing, an optimism I certainly didn’t share.
I also came out of that meeting with an appreciation of the stress and anxiety that the agency administrators were experiencing. I had begun my presentation to them by characterizing the health homes as highly complex and bureaucratic entities, whose high maintenance requirements would detract from patient care. I was assured that the Health Information Technology (HIT) system being put in place, projected to provide the coordinating glue for the homes, would address and resolve that problem. After all, wasn’t that the expectation held out by the ACA, viz., that computers and the IT networks would make everything work more efficiently and cost-effectively? Yet, when I met with the agency administrators in late April, nearly three months after the homes’ official start date in New York’s downstate counties, patients or members had only begun to be assigned to their respective health homes via a complex, two-step algorithm.
When I raised questions about training – for the care coordinators, formerly known as case managers; for the health care professionals in the hospitals and behavioral health clinics; for the patients or health home members – I was again assured that IT would handle that, largely via webinars. Webinars? Call me a Luddite but I don’t believe the passion needed to convey a sense of mission, crucial for this work, can be communicated by a trainer depicted on a computer screen. When I look at the core health home services depicted in New York’s April, 2012, “Medicaid Update,” which I have to think will provide the foundation for the key training modules, I see no mention made of relationship-building — between care manager and member; between health care providers – when we know that relationships are key to effective treatment. Nor do I see mention made of advocacy: are the health home organizers under the illusion that health care providers actually welcome the prospect of treating persons with serious mental illnesses and substance abuse disorders? The care coordinators, who will bear the responsibility of helping members negotiate their health homes, will carry caseloads of anywhere from 12 to 140 members, and will visit or have face to face contacts with their clients only when problems, such as treatment non-compliance, arise. Most of their time will be spent in front of their computer screens monitoring medical records, glorified clerks with little time for advocacy.
One of my principal concerns involves metabolic monitoring by psychiatrists and primary care physicians of those members prescribed atypical neuroleptics, particularly those like Zyprexa and Seroquel most heavily implicated in causing weight gain and insulin resistance and leading to increased mortality for those prescribed them. Once again I was reassured that the HIT system will keep the treating physicians abreast of their monitoring responsibilities. Yet QA outcomes for the homes focus on treatment compliance but make no mention of metabolic monitoring or reduction of atypical medication dosages. Further, two studies published in 2008 under the auspices of the American Diabetes Association showed that systematic monitoring of lipids and blood glucose varied from 7 to 22% of physicians studied. The studies’ authors concluded that, while physicians are, in the main, aware of the connection between atypical neuroleptics and elevated lipids and blood sugar, very few, as per the above data, actually order the requisite blood tests. I’m not confident that HIT reminders to physicians will succeed in resolving this fundamental treatment contradiction.
I’m equally pessimistic that the HIT will facilitate the provision of cost-effective care. Various studies have shown that 30% of all health care expenditures or $800 billion annually (yes, billion!) are wasted on ineffective and/or unnecessary medical procedures. It’s also been estimated, provided the Supreme Court doesn’t side with aggrieved State litigants and find the proposed Medicaid expansion coercive and therefore unconstitutional, that Medicaid expansion to cover an additional 30 million uninsured Americans will net Medicaid managed care companies $356 billion over a ten year period. I can only include that Federally-funded entitlement programs, particularly those embodied in the Affordable Care Act, are boondoggles that benefit the member organizations of the Biomedical-Industrial Complex, principally the insurance companies and Big Pharma, and much less so the ordinary Americans these programs are putatively designed to serve. Ditto New York’s Health Homes, spawned by the ACA, which will also be partnered with managed care companies. As per David Simon, of “The Wire “ fame, “Capitalism makes for lousy social policy.”
So, if I had a chance to talk to my old case managers and the clients they’ve continued to work with, what would I tell them? I would begin by advising them that the dichotomy between advocacy and technology is a false one, that the latter, technology, needs to be the complement not the replacement of the former; that advocacy, given health care providers historical reluctance to treat persons with serious mental illnesses effectively and their continued failure to conduct systematic metabolic monitoring of those persons prescribed atypicals, remains key to their clients’ successful integrated care. Interestingly, that was the same message I gave to my former agency’s top executives and middle managers when I met with them. For some reason, maybe my impassioned insistence, they listened. Or at least cocked one ear in my direction.
I would urge them to not surrender their core identities so quickly; to remember that, in the end, they’re advocates, charged with the well-being of vulnerable individuals, not glorified clerks, whose ultimate task will be to help their clients leave a system that does them more harm than good. And I would conclude my talk by reminding them, Don’t mourn, organize!
One more thing … Boycott DSM5!
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Brody, H., “From an Ethics of Rationing to an Ethics of Waste Avoidance,” New England Journal of Medicine, May 2, 2012, http://www.nejm.org
Brooks, M., “Metabolic Screening in Antipsychotic Users: Whose Job Is It?,” Medscape, May 8, 2012, http://www.medscape.com
Carney, J., “Mental Health Homes Open Their Proverbial Doors In New York: Parts I & II,” February 7 & 10, 2012, www.madinamerica.com
Gomory, T., et al, “Clinical Social Work and the Biomedical Industrial Complex,” Journal of Sociology and Social Welfare, December, 2010, firstname.lastname@example.org
Jost, T.S., “Is Medicaid Constitutional?,” New England Journal of Medicine, May 3, 2012, http://www.nejm.org
Mental Health Weekly, “Health Care Delivery System Prompts New Workforce Role for Case Managers,” April 30, 2012, www.wiley.com
New York State Department of Health, “Introducing Health Homes,” New York State Medicaid Update, April 2012, Vol. 28, #4, www.nyhealth.gov
New York State Office of Mental Health, “Transition from Targeted Case Management (TCM) to Health Home Care Management and non-Medicaid Funded Care Management – Interim Instructions,” February 21, 2012, http://www.onh.ny.gov
Phend, C., “ADA: Metabolic Monitoring Guidelines for Antipsychotics Largely Unheeded,” Medscape, June 10, 2008, http://www.medscape.com
Stuart, H., Arboleda-Florez, J., “Community Attitudes Towards People with Schizophrenia,” Canadian Journal of Psychiatry, Vol. 46, #3, April, 2001, pp. 245-252, http://www.ncbi.nih.gov/pubmed