From day one, it was clear that Donald Trump was like no president this country had ever seen. Eight months into his term, we talk to Harvard Law professor Jack Goldsmith about the lasting impact Trump may have on the presidency, itself. Then, historian Dan Jones on the Knights Templar, the Medieval secret society that inspired "The Da Vinci Code".
The deadly Colorado shooting underscores the need to better identify, diagnose and treat people with mental illness. Diane and guests will discuss the future of mental health services under the Affordable Care Act.
- Dr. Steven Daviss Chairman of the psychiatry department at the University of Maryland Baltimore-Washington Medical Center.
- Rachel Garfield Senior researcher and associate director of the Kaiser Family Foundation.
- Pamela Hyde Administrator of the Substance Abuse and Mental Health Services Administration.
- Richard Frank Professor of health economics at Harvard Medical School.
MS. DIANE REHMThanks for joining us. I'm Diane Rehm. Recent studies show that one-third of American adults suffers from mental health disorders, and most of these go untreated. The deadly Colorado shooting underscores the need to better identify, diagnose and treat people with mental health problems.
MS. DIANE REHMJoining me in the studio to talk about how the new health care law would affect the provision of mental health services: Richard Frank of Harvard University, Pamela Hyde of the Substance Abuse and Mental Health Services Administration, Dr. Steven Daviss of the University of Maryland, and Rachel Garfield of the Kaiser Family Foundation. Feel free to call us, 800-433-8850. Send us an email to email@example.com. You can follow us on Facebook or Twitter. Good morning to all of you.
MS. RACHEL GARFIELDGood morning.
MS. PAMELA HYDEGood morning.
DR. STEVEN DAVISSGood morning.
PROF. RICHARD FRANKGood morning, Diane.
REHMGood to have you here. Rachel, if I could start with you, as I said at the outset, about one-third of American adults, one-fifth of children have some kind of mental health disorder. They're the leading cause of disability in the U.S. and Canada. Of those, how many actually get treatment in this country?
GARFIELDWell, what research shows is that a surprisingly large share of people, who have a diagnosable disorder, go without services. Studies show that between half and 60 percent of adults with a diagnosable disorder went without services that they needed. And the main reason that people say that they didn't get the services they need is because they could not afford the cost of care.
REHMAnd, Richard Frank, how many Americans suffering from mental illness are actually uninsured?
FRANKIt's about 20 percent overall that -- among the people who are diagnosed with a disorder that don't have coverage.
REHMAnd what is that actually costing us as a society?
FRANKWell, it costs us in several ways. First of all, it costs us in putting extra burden on states and local governments because people wait till very late in their illnesses to get treatment. It costs us in lost work productivity because people don't get treated and lose their jobs and are absent from work. And it costs us through a variety of other social problems that are a consequence in mental illness, such as homelessness.
REHMAnd, Steven Daviss, a lot of people wonder, what are the early warning signs of serious mental disorder?
DAVISSSo there are a number of mental disorders to think about: depression, bipolar or anxiety. When it comes to serious mental illnesses, we usually include the mood disorders, schizophrenia. These can be very severe, and the symptoms vary. So you would expect in depression, for example, to see problems with sleep, appetite, energy level, concentration and problems functioning, say, at work or at school. For somebody with a psychotic condition, you start to see problems with withdrawal and also in more severe cases, delusions, paranoia, hallucinations.
REHMAnd we now know that the Colorado shooting suspect, James Holmes, who's now actually been charged, was under psychiatric treatment for we don't know exactly what. But the question is, when does a psychiatric professional feel the obligation to report that kind of illness to some higher authority?
DAVISSSo I -- from state to state, there are different laws about what the level, you know, at what point you cross that line and break a patient's confidentiality because of public safety.
REHMGive me an example.
FRANKSo an example would be in Maryland. For example, one has to demonstrate dangerousness to oneself or to others, and there needs to be fairly clear evidence of that. And one of the challenges that we oftentimes face in treating patients is when someone has much more vague risks or concerns. They don't come out and say, I'm going to shoot my father tomorrow, but instead say something like, you know, I hate these people. And one of these days, I swear, who knows what'll happen. That's very vague. And how do you respond to that is...
REHMSomebody picked up the phone the other day here in the Washington-Maryland area and threatened a former supervisor in exactly that way.
DAVISSAnd, of course, some of the people that make these threats don't have a mental illness and are criminal. And, you know, how do you cross that line, too?
REHMPamela Hyde, turning to you, explain to us what the Substance Abuse and Mental Services Administration does to address these widespread problems of mental health.
GARFIELDSAMHSA -- that's the acronym for my agency -- has a responsibility to provide information, training the professionals, policy at guidance, as well as money, grants and resources to all states, as well as to various grantees who apply for dollars from my agency. We also play a role in making sure that people in America have places to call when there is distress or when there is concerns. And we have programs that we work with to try to train people or teach the lay public as well as first responders about how to respond to people who are having mental health issues.
REHMSo if someone were -- say a psychiatrist were to call your agency and say, I have a patient, and I'm really, really concerned about what this patient might do. where is the line of professional responsibility on the part of the therapist, the line of privacy and protection of that patient?
HYDEOn any given individual situation, we certainly would ask a professional to deal with their local laws and their local responsibilities because, as Steve said, it's different in different places. What our job would be to do is to help get them materials or information, provide technical assistance and provide some guidance and direction about where they might seek some help or direction. Generally speaking, we don't get calls about clinical situations.
HYDEGenerally, we get more calls about practice orientation and programs that might be helpful, including -- we have a national register of evidence-based practices that we help provide information to practitioners as well.
REHMPamela Hyde, she is administrator of the Substance Abuse and Mental Health Services Administration, otherwise known as SAMHSA. Now, turning to the Affordable Care Act, Rachel Garfield, how does the new law expand access to mental health services?
GARFIELDWell, the main way that the law will expand access is through the expansion of insurance coverage to millions of people who have mental health needs. And it does that through two major coverage provisions. The first is the establishment of what are called health insurance exchanges. These are marketplaces where people who are purchasing coverage on their own will be able to go.
GARFIELDAnd most of them will receive some sort of subsidy to help purchase that coverage. The other major coverage provision is the expansion of Medicaid to many low-income people, primarily adults, who are currently not eligible for that coverage.
REHMAnd what's in operation right now?
GARFIELDRight now, some of the early provisions that have gone into effect are some states have expanded their Medicaid programs ahead of schedule to make coverage available to people who were previously not eligible for coverage. In addition, some early reforms to the health insurance market have gone into place, things like allowing young adults to stay on their parents' coverage up to the age of 26. But most of the major provisions of the law go into effect in 2014.
REHMAnd if those states decide that they're not going to incorporate those provisions, those individuals then are left out. Is that correct?
GARFIELDCorrect. With the recent Supreme Court ruling, the expansion of Medicaid was upheld. However, what the court did was basically said that the secretary's ability to enforce that expansion was limited. And so that means in some states, they may not expand the Medicaid program, and that's going to mean that the lowest income people in those states may be left without a coverage option.
REHMAnd, Richard Frank, what about the concept of parity with physical health services?
FRANKThe notion of parity has been around a long time. But in 2008, the so-called Domenici-Wellstone Mental Health Parity Act was enacted, and that turns out interacts with the Affordable Care Act by requiring that mental health services be treated and mental health and addiction services be treated in a no more restrictive way than all other medical care.
REHMWhat does that mean?
FRANKWell, that means that you can't put special limits. So, for example, if you look back a few years, the typical health insurance policy had 20 visit limits and 30 in-patient day limits on your coverage. That is no longer the case for employer-sponsored insurance.
REHMRichard Frank, he is professor of health economics at the Harvard Medical School. We'll take a short break. I see we have many callers waiting. We'll get to you as quickly as possible. Stay with us.
REHMAnd we have our first email from Bernadette in New Hampshire, who says, "Thank you from the bottom of my heart for discussing this issue. It's been kept out of the public domain for many years as people were shamed and humiliated into thinking it was their fault they had family members with mental disease. I grew up during the '50s and '60s not knowing the whys and wherefores of these many brain disorders."
REHM"The medical profession needs to come forward to discuss these issues in a public forum." And that's precisely what we're doing now. Has some of the shame passed away from us, Steven Daviss?
DAVISSI believe it has. I think the evidence suggests that, too. The number of people asking for and receiving mental health treatment has increased over the years. It's something that people are now able to talk about more openly, whereas before they would just whisper about it. Many years ago, medical problems like cancer and epilepsy also had the stigma, and no one talked about it. And that has changed. So I think we're seeing that with mental health.
DAVISSBut until -- right now, there's still a lot of insurance discrimination despite the Mental Health Parity Act. We don't have final regulations yet, and it's four years later. And so -- and even Medicare, for example, discriminates as far as co-payments. That's in the process of changing. I think, in two more years or so, it will be even. But when people see that the government discriminates against mental health, it makes it kind of a fair game for everybody else. That's changing now.
REHMAnd what is the situation of parity in the state of Maryland, for example?
DAVISSWell, we are starting to see some changes in insurance company behaviors, especially with respect to things like getting prior authorizations, these long, sometimes 10, 15, 20, 30 minutes sometimes phone calls, where you -- a clinician has to explain what's wrong with the patient and why they deserve this treatment to get the authorization. We're seeing less of that. It's still happening to some extent with inpatient hospitalizations.
DAVISSAnd I think -- so these are some changes, but the problem is that the parity law requires that you compare the restrictions that are on the physical health insurance side and the mental health insurance side 'cause a lot of times, mental health is what they call carved out, and there's a second company managing that. The challenge is that oftentimes the insurance companies refuse to give assist information because they say its proprietary information.
REHMYou know, it's interesting. I would wonder about somebody on the other end of the telephone if that's an insurance company agent evaluating the mental health needs of an individual who's come to a psychiatrist. Richard Frank.
FRANKWell, there are -- there's a variety of practices out there. And while most companies, I think, are actually quite responsible, higher-trained clinicians very often to be on the other end of the phone, there are obviously some companies that cut corners and are more aggressive and less responsible in terms of getting people into care.
REHMAnd how would that change as far as the Affordable Care Act?
FRANKWell, the Mental Health Parity Act did two things. One, it required that the limits that I discussed earlier go away. But it also required that the care be managed on par between the health care, medical care side and the behavioral health side. And so Steve's point about prior authorization being eased is a reflection of that set of regulations.
REHMAnd, Pam Hyde, is that same scenario likely to occur? How could it negatively impact the benefits of the ACA?
HYDEActually, I think that there is very little way that it's going to be negative. I think that what we are understanding more, and more in both clinicians and payers are understanding this is a public health issue. We tend to think of it as a culture, as a problem instead of as a public health issue. So, increasingly, people are understanding that getting early screening is actually going to save money in the long run and to the extent that insurers are beginning to understand that, and we're beginning to work significantly.
HYDEAnd SAMHSA does a lot of work on integration of behavioral and primary care so that regular clinicians, primary care physicians can screen for alcohol use, substance abuse, depression and other kinds of early issues. We know there's a lot of what we call comorbidity between health and behavioral health issues. And we also know, frankly, that the health care costs are a lot higher when there's untreated behavioral health issues, so I think payers as well as clinicians are starting to understand that treating this like a heath issue is much more cost effective as well as good for people
REHMGive me an example of how you see that the cost of not treating becomes even higher than the cost of treating.
HYDESure. Someone who has this diabetes, for example, and has a co-occurring alcohol issue or a co-occurring depression, the data shows us that it's going to cost about four-and-a-half times to treat the diabetes if there's untreated behavioral health issue because people are less likely to seek care or be able to comply with care and because there are interactions between both the behavioral health and the health care issue.
GARFIELDYeah. I mean, I think one of the things that the Affordable Care Act does in addition to the coverage provisions that we've been talking about is there are a host of pilot projects and other initiatives to improve service delivery for individuals with mental illness to address these problems that Pamela's talking about, of integration and coordination, which is really important in particular for this population due to the fact that there is a high degree of what we call comorbidity where people who have both the mental illness and a physical illness.
REHMYou know, these are all very highfalutin words. At the same time, one begins to wonder, considering the fact that some states have already opted out of the Medicare portion, how is that fact, the fact that these states are opting out going to effect how much mental health treatment those states allow?
FRANKWell, I guess there's two issues. There is -- we don't know who's really opting it and who's opting out.
REHMIt's going to take some time before we really know how many are going to take the money on the table.
FRANKRight. There's a lot of money on the table, and states are in a really rough shape financially. We get reports every other week. So, you know, it's one thing in an election year to make claims. It's another thing to face the budget and the real uninsured and mental health problems that your population really has and say you're going to walk away from tens of billions of dollars.
REHMSo even states like Florida and Texas?
FRANKWell, we're -- actually, Florida's an interesting case because recently, you've started to see some pushback from various parts of the business community and human service sector in trying to get the governor to pay attention to the opportunities created by the Affordable Care Act.
HYDEDiane, I think it's also important that the states pay for these issues anyway. They pay for them in untreated mental health issues that result in jail issues, that result in homelessness, that result in other things that, frankly, states pay for, states and local communities. So I think part of the issue is states are going to have to look at again, is it better to treat this as a public health issue with assistance from the federal government in dollars, or is better to continue to have these untreated issues?
REHMBefore we open the phones, Rachel Garfield, talk about the concept of health homes.
GARFIELDHealth homes are something that was established in the Affordable Care Act. The idea here is to get at these issues of integration that we've been talking about. So if you think about someone who is facing multiple illnesses is probably seeing many providers, different types of providers, one provider for their mental health, one provider for their diabetes care, maybe another for cardiology care.
GARFIELDWhat the health homes aims to do is provide an integrated place so that person -- excuse me -- knows where they can go to have a coordinated system, that the providers are interacting with each other, that health records are integrated so that one provider knows what the other one is doing. And many states have expressed interest in establishing these and are currently getting their systems up and running.
FRANKWell, I -- and I think this builds on a sort of a new philosophy, which is to meet people where they are -- that is, that no longer is the patient responsible for doing all the work, that, in fact, we're going to have this coordinated care of these where the patients lie. So a mental health center can be a health home. A primary care office can be a health home. And that's a big step forward to trying to really bring the services to the patient.
REHMSo mental health, physical health create the whole person.
DAVISSAnd that's why, I think, many states are starting to look at how to integrate these two types of services together to save a lot of this -- Pam talked about the cost for someone with diabetes and mental illness being four times higher. So that's a lot of money on the table that could be saved. In the state of Maryland, for example, under our secretary, Joshua Sharfstein, we are in the process, this past year, of integrating mental health and addictions, which have been separate for over 10 years now.
DAVISSBut we're also trying to -- we're talking -- having a discussion about integrating physical health as well. There are challenges with that because the question is do you continue the same system where you have two different companies, one managing physical and one managing mental health?
DAVISSAnd it's hard to integrate when the two different companies are managing it.
REHMBut what about, Pamela, the privacy concerns here, that individuals would think, well, who has access to the information about my whole being?
HYDEI think privacy concerns are important, whether it's physical paper records or whether it's electronic records. There are particular privacy concerns for substance abuse treatment issues. So one other thing: SAMHSA does two things. One is we are responsible in the law for consulting with states who are trying to put together health home approaches for people with serious mental illness.
HYDEWe're also responsible for and have taken on work with the electronic health records to look at privacy and data segmentation issues and consent issues. We're working with the -- what's called the Office of the National Coordinator for electronic health records and trying to look at those issues so that as we develop more and more electronic health records, anybody -- whether it's physical or behavioral health issues -- can have consent over what gets released and what doesn't.
REHMSo that if I'm taking a certain kind of drug, for example, and I say, I'd rather that that information not be released, but suppose it's a drug to treat me for some really serious mental illness, does my right to privacy override the public's need to know about me?
HYDEPrivacy for any kind of health record overrides most any public need to know. The assumption that just because I'm taking medication for a particular kind of mental health issue would somehow make me a danger to the public, it's just not accurate. By and large, people with mental health issues, especially with serious mental health issues, are much more likely to be victims than perpetrators.
REHMPamela Hyde, she's administrator of the Substance Abuse and Mental Health Services Administration. And you're listening to "The Diane Rehm Show." Of course I'm not going to get you all into a legal discussion, but this issue certainly is going to come up as far as James Holmes is concerned and the type of medication he may or may not have been on, whether, in fact, he was a potential danger to the public. Of course, how can anyone really know? Could he perhaps have been cured?
DAVISSI think that one of these -- when a tragedy like this happens, people try to learn as much as they can about it 'cause they're trying to figure out, how can I reduce my risk and the risk to my family? So they learn all these details. And when there's no information forthcoming, they sometimes apply their biases. And one of the biases that I sometimes hear is that people with mental illness are more likely to cause violence to others when, in fact, they're more likely to be victims of violence rather than perpetrators.
DAVISSWhat Pam was talking about before, about the privacy and electronic health records, as the country increasingly adopts these electronic health records to store information and they become interconnected with health information exchanges -- in Maryland, every single hospital is connected to a health information exchange -- it's important for patients to know what happens to their information and who has access to it because...
DAVISS...if they don't trust it, maybe they won't get treatment, and things could get worse.
REHMInteresting. All right. Let's open the phones, 800-433-8850. First to Portsmouth, N.H. Good morning, Julie. You're on the air.
JULIEOh, good morning, Diane. I'm so excited about this discussion, and it's long overdue that we have more discussions such as this. My situation is I am suffering from bipolar as well as PTSD, and I have addiction problem. However, I've spent a few years without any substance, thank God. I have found that the medical community is not up to par or up to speed regarding mental health issues. The -- I've had a long-standing relationship with a -- my family physician, who's actually said to me, are you sure you're bipolar, just due to lack of understanding.
REHMWell, have you actually been diagnosed as being bipolar by a qualified therapist?
JULIEOh, I certainly have been, but...
JULIE...I actually spent some time at McLean...
JULIE…which is a fabulous facility, but I've seen patients released from McLean far too soon.
REHMRichard Frank, is there, in your opinion, a lack of knowledge on the part of general practitioners about mental health disorders? And is there an effort to try to upgrade their education?
FRANKI think there's many years of research that shows that mental health problems and addiction problems tend to be under-recognized and under-treated in primary care settings, but that, in fact, that's been improving over time and...
REHMI hope so. Richard Frank, he is professor of health economics at the Harvard Medical School. Short break. Julie, good luck to you, and thanks for calling. We'll be right back.
REHMWe're talking about mental health issues, how they are covered and will be covered under the Affordable Care Act. Just before the break, Pamela, we were talking about the training -- upgrading in training for physicians, and, I gather, your administration is working in that direction.
HYDEThat's correct. We have a number of programs that are working to train private practitioners and physical health practitioners about how to do quick and early screening and about how to understand mental health and substance abuse issues. We have a technical assistance center that's specifically targeted to that, and we have grant programs that are specifically targeted to that. We work very closely with an organization called HRSA, which is a sister agency with NHHS who does a lot of primary care, and we do that technical assistance work together.
REHMAnd, Rachel, what about the Kaiser Family Foundation also working in that direction?
GARFIELDWell, our role is really to provide information to policy makers and the public about what's going on with health policy. So a lot of the work we're doing is explaining to people what's in different new initiatives such as the Affordable Care Act, who's going to be impacted and what the implications are going to be for how they're going to receive their healthcare services.
REHMAll right. To Charlotte, N.C. Good morning, Larry.
LARRYGood morning, everyone. Your introductory remarks kind of struck me that, apparently, it's generally agreed that nearly a third of the population has a diagnosable and presumably treatable mental health condition. My question is this -- or two questions. Are we over-diagnosing mental health conditions? And if a third of the population has a condition for which they need treatment, that's roughly, what, 70 or 80 million people, how can we treat these people, and how can we possibly afford it?
REHMGood question. Richard Frank.
FRANKWell, I think one has to dig behind the numbers a little bit in order to get this. Because you have a diagnosable condition doesn't necessarily mean that you need a lot of treatment. In many cases, you know, watchful waiting is the right thing to do. In other cases, the potential problem doesn't really affect the way you conduct your life. And so those cases wouldn't need the kind of treatment I think you're referring to whereas other cases do.
FRANKAnd we, you know, the -- I think the key point is that we do under-treat mental disorders and addictive disorders in this country. And then the question is by how much.
REHMAnd then the question becomes if the Affordable Care Act is going to provide additional coverage, how much and how much is that likely to cost, Richard Frank?
FRANKI think that, overall, what we've learned in the last few years is that because we've gotten so astute at managing behavioral health care in this country, you can do considerable amounts of insurance expansion without dramatically increasing the cost. Now, clearly, when you treat more people and you do it well and you do it seriously, it's going to cost more money. On the other hand, by doing it earlier and by doing it in a more focused way, there are opportunities to save money by getting people into care earlier.
REHMHere's an email from MC in Rolla, Mo. "Do your guests have even one example of a seriously mentally ill person who has been fragmented from acting out violently by their therapist, warning the authorities?" Steven Daviss.
DAVISSSo for -- if a therapist is seeing somebody and they're concerned that somebody has -- is imminently dangerous...
DAVISS...oftentimes, what they would do is they would encourage them to seek in-patient treatment. If they refuse to, then every state has legal mechanisms that can compel somebody to be evaluated and, if necessary, hospitalized even against their will if they're in some imminent danger. We treat patients at my hospital, Baltimore Washington Medical Center, on a daily basis in our ER who come in with clear risk. And I think that, many times, things are prevented. But, of course, with prevention, you never really know what you're preventing.
REHMAll right, thanks for that. And to Mark in Independence, Mich. Good morning. You're on the air.
MARKGood morning. With over 18 million diagnosed alcoholics, or at least estimated, in the United States, I'm wondering what differences the ACA makes in terms of treatments and options available for their treatment.
GARFIELDSo one of the things that we haven't talked about so far this morning is the scope of services that people are going to get when they acquire new coverage. Under the law, there are general categories of coverage that are going to have to be covered by all insurance plans, and these include both mental health and substance use disorder services.
GARFIELDNow, the exact extent of what -- how those are going to be defined are going to be left to the states to determine what types of limits might be on those services. But there's a big step forward in expanding insurance coverage for both mental health and substance use disorders.
REHMDo you want to add to that, Richard?
FRANKSure. I think that on the addiction side, the Affordable Care Act will have among its most dramatic effect because insurance coverage for addictive disorders has been so incredibly limited, both in the private sector but also in many Medicaid programs. And so I think the Affordable Care Act is going to have a particularly large impact on people being able to get treatment through insurance mechanisms.
REHMMark, does that answer it for you?
MARKIt does in part. I'm also wondering whether there's likely to be any increase in integration in the physical and mental aspects of addiction and their treatment.
HYDEThat's a great question. In fact, some of our best screening tools are for alcohol use before it becomes an addiction. So that's part of the point of some of this early prevention care. One of the things the Affordable Care Act adds is prevention activities and prevention services for -- without a co-pay. So screening for depression, screening for alcohol, screening for tobacco use, those kinds of issues are going to be available in many circumstances without a co-pay for people.
REHMHere's an email from Daniel, who says, "I hear your guests say that screening saves money, but there's no free lunch. Economists have near universally found that screenings cost money because customers demand screenings whether or not they save money and whether or not they improve health." Richard Frank.
FRANKWell, I think, certainly, there's quite a bit of evidence suggesting that screening increases spending, particularly in those service areas. I think, on the other hand, when you have a set of circumstances like you do in mental health and substance use problems where the under treatment is so dramatic and, in fact, a manifestation of the illness is to say that you actually don't need care, the screening can have a really important role in getting people timely treatment that will be effective and ultimately return them to functioning more quickly.
REHMWhat kind of screening are you talking about, Steven Daviss?
DAVISSSo one of the screenings for alcoholism is just a four-question tool. It's called the CAGE, and a physician would ask or maybe they would use a form and ask a series of questions to determine what the alcohol usage is and how it's impacting ones life. There are other tools, too. There's the AUDIT-C, and there's the M3, which also monitors for depression and bipolar disorder.
DAVISSSo I think as primary care doctors start to get paid for doing these screenings, whereas before it was just added, added, added and you only have a certain amount of time so you don't have time to do it, I think that will definitely increase the amount of utilization of the screening tools and help to cut back on all these excess medical cost because people don't take care of their chronic medical conditions.
HYDEOnce -- when we talk about these issues, we tend to think just about the healthy delivery system. And we started the show by talking about how much loss productivity for employers -- that's particularly true for alcohol issues --how much costs in jails and homelessness and other kinds of issues for serious untreated illness. So when you think about the cost of something that's so simple as a screening and compare that to the cost that we as a society are paying in the broader world, these are not even comparable.
REHMYou know, there's another cost out there which is the cost of losing primary care physicians. The shortage thereof surely is going to impact exactly how well and broadly individual patients are treated. Pamela.
HYDEOne of the things the Affordable Care Act does is provide dollars that HRSA and HHS have used to really increase the primary care practitioner pool. The -- HRSA, our colleague agency, has done significant work in getting more primary care doctors into the stream. And some of those dollars have really increased those numbers.
REHMAnd, you know, you come down to dollars again, paying off student loans, paying off medical school loans. and how you can do that in a system that pays so little to the primary care physician who is so vital in this entire process? Rachel.
GARFIELDYeah. And one thing to add to this discussion, it's not just the question of numbers of providers in the country. It's also a question of distribution. So where...
REHMOf course. Yeah.
GARFIELD...are those providers choosing to practice? And also, what types of settings they're choosing to practice in? Really, one of the goals of a lot of policymakers right now is to try to get more providers practicing in community settings, to increase participation in the Medicaid program so that we have more availability for people who are traditionally underserved.
REHMAnd to Julia here in Washington, D.C., you're on the air.
JULIAOh, Diane. Thank you so much for taking my call.
JULIAAnd I so appreciate all of your guests for talking about this issue. I don't think that your listeners could possibly understand what it's like to have a child with paranoid schizophrenic. And that's what happened to me. My son went to private schools here in Washington. He had a terrific upbringing, very well adjusted little boy. And when he was 15, again, he had the onset of schizophrenia. And I want your listeners to know how serious this is.
JULIAWe used the term mental illness, but, really, when you have a delusional child who's catatonic and suicidal and -- I mean, this is really big, big issue. And he has Blue Cross Blue Shield. And I was expected to care for him at home after he got out of a hospital at St. Elizabeth. And it's been really just unbelievable. So thank you very, very much for hearing my comments, and I'm thrilled that we got this discussion going. And I so look forward to the day when we can have some really decent and good quality housing for people who are delusional.
REHMI appreciate your call, Julia. And you're listening to "The Diane Rehm Show." On that point, Richard Frank, you've had so many states closing down mental institutions where a boy like Julia's son might have been helped and cared for.
FRANKWell, here is a place where there's optimism. We have learned a tremendous amount about what to do to support people, like Julia's son, in the community. And we've had just enormously positive experiences with things like supportive housing and community treatment programs, things known as sort of community treatment programs. And they are specifically designed for people who are the most disabled and the most ill. And they've been shown to be cost effective.
FRANKAnd so I think that that's a note for optimism because we can now do well by these people and not take away their civil rights and lock them up in distant state hospitals that treat them only in minimal ways.
DAVISSRichard's absolutely right about these community services as the ACA unfolds and these health benefit exchanges unfold. One of the concerns is, will they cover these community services, these residential treatment programs, crisis beds, things like this, or will they just do the standard out-patient hospital and that's it? That's a question that states are struggling with because of the cost but because of the intense needs for the most severely ill.
REHMHere's an email from Mark, who says, "As a family physician, I try very hard to address my patients' health care needs, but part of the problem is reimbursement. One day, I removed a mole from a person's arm and then later in the day, talked a patient out of committing suicide. The first patient took me 15 minutes. The second person I spent over 90 minutes with. Guess which one paid better?" Richard Frank.
FRANKWe have pricing problems throughout the health care system, and that's reflected in a variety of ways. It's reflected in the case that you just cited. It's also reflected in the way we play -- pay for procedures versus just a whole variety of primary care services that require what we called cognitive time.
REHMWell, is that going to change under the ACA, Pamela?
HYDEOne of the different approaches that is allowed under the Affordable Care Act -- and we're really pushing -- is these integrated care models where multidisciplinary teams can work together. And it's not always the physician who's going to have to do some of this work, mental health professionals embedded into primary care settings or pure practitioners doing a lot more work with. I think as these account care organizations or health homes or these integrated care approaches are put together and paid for differently, this will offer some different opportunities.
DAVISSAnd, Diane, I think that what we're starting to see more and more now is this notion that health care providers will start to get paid based on how well they keep somebody well on their outcomes and not on how many times they see him, how many visits they have, how many times they cut a mole off.
REHMWell, let's hope that whatever happens, mental health issues are taken seriously and treated effectively. Thank you all so much.
REHMSteven Daviss, he is chair of the Department of Psychiatry at the University of Maryland's Baltimore-Washington Medical Center. Richard Frank, professor of health economics at Harvard Medical School, Rachel Garfield of the Kaiser Family Foundation, Pamela Hyde of the SAMHSA. And thank you all for listening. I'm Diane Rehm.
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