How to Navigate the (Broken) Behavioral Health/ Mental Heath System
Attaining good mental health treatment is an odyssey unto itself. Many shoals and barriers exist along the way to appropriate care. These can be broken down into two large categories: knowledge of behavioral health symptoms and knowledge of the behavioral health system. I am concerned with both sets of issues, as both serve as major weak links in the treatment chain. I have elsewhere written about the appalling lack of knowledge on the part of most individuals regarding mental health issues and mental health problems, made all the more astonishing by the evident fact that most of us are dealing with mental health issues, if not problems, 24 hours a day, seven days a week. I have argued previously for a mental health track to be included in all educational grades from kindergarten through college as a major step forward to reducing the incidence of behavioral health problems and behavioral health dangers such as suicide.
Here, however, I hope to describe how the American behavioral health system is meant to function in its pure state, and how it functions and dysfunctions in its real state. It is important for the consumer to understand the way the system should function, the ways it does not function, and what the mental health consumer should do to compensate for these systemic issues. This knowledge will help people navigate and otherwise creaking, archaic behavioral health system for themselves and their significant others.
How the Behavioral Health System Should Work
Behavioral health treatment is provided in distinct levels of care. The lowest level of care is outpatient treatment, either in the form of therapy or psychopharmacology and performed either by a psychiatrist, or a psychologist, social worker, or other behavioral health counselors who do therapy only. Therapy in this case is done anywhere from twice a week to once a month, though some psychopharmacological work is done by psychiatrists every three months for stabilized patients. Individuals who are appropriate for outpatient treatment are those who are functioning reasonably well in their daily lives, but who are suffering symptoms which nonetheless impede their full functioning, such as anxiety, depression, hypomania,; or, patients who are having difficulty in their relationships, with their psychological issues, or with their inability to cope with normal or excessive external stress. Therapy may take different forms, including psychoanalytically informed psychotherapy, behavioral therapies, cognitive behavioral therapy, interpersonal therapy, and dialectical behavioral therapy. Individuals who are appropriate for outpatient treatment pose no danger to themselves or others and, for the most part, are able to carry on their normal daily lives, though with barriers and inefficiencies stemming from their personalities and/or symptoms.
It is important to understand the difference between psychiatric treatment and psychological treatment, though some psychiatrists still practice both. For the most part, psychiatrists currently focus their attentions primarily on conditions which produce symptoms amenable to psychopharmacology, that is to say, psychiatric medications. These conditions include all the anxiety disorders, depression, bipolar disorder, some schizophrenias, obsessive-compulsive disorder, eating disorders, autistic disorders, posttraumatic stress disorder, and attention deficit hyperactivity disorder. Psychologists, psychiatric social workers, counselors, and some psychiatrists also participate in the psychotherapies noted earlier. These therapies deal with the interpersonal problems, psychological issues, and environmental stressors which are generally not amenable to medical-psychiatric treatment. They are, however, amenable to the variety of talking treatments specified previously. It is important to understand the symptomatic syndromes treated by psychiatrists often worsen the co-occurring psychological, interpersonal, and environmental issues that are comorbid. Ideally, then, all behavioral health patients should be evaluated first and foremost by a psychiatrist to rule out the existence of symptomatic syndromes(collections of symptoms) which can be treated more quickly and efficiently by the psychiatrists medications. Symptoms associated with the psychiatric syndromes are truly the "low hanging fruit" of mental health treatment
To say this from the opposite point of view: One often sees patients who are suffering significant anxiety, depression, and bipolar symptoms who, not knowing where to turn for treatment, naturally seek out a talking therapist first. Two years of treatment may go by and little may have been accomplished by talking treatment alone, so long as the symptomatic syndromes are left untreated medically. Only then may the therapist suggest that it would be useful to seek a consultation from the
psychiatrist. The patient has lost two years of potentially greater functionality by entering the behavioral health system at the wrong point.
Above the outpatient level of care is the intensive outpatient setting. Individuals deemed appropriate for this setting are those whose symptoms are sufficiently intense that they cannot successfully master their activities of daily living. These might include the inability to take care of their children, take medications for diabetes properly, maintain employment, bathe and feed themselves. Generally, appropriate individuals are not a danger to themselves or others when admitted to the intensive outpatient setting. In practice, intensive outpatient treatment consists of three visits per week to the intensive outpatient program, usually two to three hours per visit. Treatments include medication therapy, individual therapy, group therapy, and general monitoring for safety concerns. Therapist of various specialties man these programs, including a psychiatrist for the medical/psychiatric care. At times, intensive outpatient programs are subdivided into those which treat borderline personality disorders, obsessive-compulsive disorders, depressive disorders, etc. At other times the intensive outpatient program consists of a mix of diagnoses rather than the sub-specializations.
A yet higher level of care is the partial hospital program. Here, the patient is not only unable to function in terms of his or her activities of daily living, but also poses a subacute danger to himself or others. This is a technical way of indicating that the patient has some thoughts of suicide, perhaps some thoughts of hurting others, but is not considered an imminent danger to carry out any of these acts, which remain at the level of contemplation only. These programs are difficult to find, but also manned by a variety of behavioral health specialists as well as a psychiatrist. The program length is all day five days a week, but the patient is home in the evenings and on the weekends. There is much careful monitoring done for suicidality and homicidality, as would be expected for individuals who are having current thoughts of harming themselves or others. It would be incumbent upon the therapist and the patient to monitor these thoughts and prevent them from leading to the point of action.
The highest level of behavioral healthcare is the inpatient setting. This program is reserved for patients who are acutely suicidal, acutely homicidal, or for those patients whose symptoms are so severe that they pose an imminent danger to their own health or welfare. An example of the last category might be an individual with schizophrenia who is not in any sense physically threatening to self or others but was unable to manage taking ahis psychiatric or medical medications appropriately, to the point of putting his health in danger. These hospitalizations take place in a psychiatric unit attached to a large General Hospital. Whereas in years past a psychiatric hospitalization might have lasted anywhere from two weeks to several months, current managed care practiceshave limited these hospitalizations to an average length of stay of approximately 5 to 7 days nationally.
For the system to function smoothly and effectively there needs to be seamless and timely coordination amongst the various levels of care. This would also imply that all levels of care should be, optimally, provided within the same institution. In addition, there needs to be rapid and clear communication channels amongst the various treatment settings. For instance, if a patient were to require immediate hospitalization from the outpatient setting, the outpatient physician should be able to contact the inpatient department so that the hospitalization be effected quickly and safely. After all, the individual is considered to be an imminent danger to himself or others and needs immediate monitoring and protection. In a reverse fashion, patients who are being discharged from an inpatient setting need to be able to be transitioned quickly to a partial hospital setting or to an intensive outpatient setting. This is especially important because the act of discharge is fraught with multiple dangers. For one, it often takes many weeks to get an outpatient appointment with a psychiatrist and with the therapist. More importantly, however, the transition from inpatient treatment is associated with a high level of suicidal behavior. In fact, one of the most significant risk factors for suicide is the week post hospitalization. The patient, after all, is leaving a protected and secure environment, and is being thrust back into the selfsame arena where he or she may have experienced stressors which led to the hospitalization. For this reason, it is imperative that best practices include a discharge to a partial hospital or intensive outpatient setting for all inpatient discharges.
In order for patients to transition easily from one setting to another, there would need to be ample funding for appropriate staff and ample spaces for the new patient to fit into all the settings.
How does the behavioral health system function in practice?
For most institutions, the de facto behavioral health program falls far far short of the ideal, and is woefully inadequate. It is for this reason that patients, and especially significant others who are attending to the patient, need to understand the barriers and pitfalls they will be encountering in navigating through this arcane system. In fact, the significant others of necessity will need to be advocates for the patient and help smooth the transitions when the system fails them.
In point of fact, most institutions do not provide all the necessary levels of care. A typical large hospital may have an outpatient department, a small inpatient unit, and occasionally intensive outpatient program. It is very rare to see all four levels of care within the same institution. In fact, it is quite rare to find a partial hospital setting anywhere. Related to this, Medicare pays for outpatient and inpatient but not necessarily for both intensive outpatient and partial hospital treatment. Moreover, the co-pays required for intensive outpatient can be quite burdensome to financially strapped individuals, as they are paying an outpatient co-pay three times per week. This financial barrier often blocks the patient from seeking or accepting intensive outpatient care.
In terms of the treatment venues, the outpatient treatment may be taking place in a private practice setting having no communication lines whatsoever with the large institution that may provide the intensive outpatient program or inpatient programs. Unfortunately, even programs housed within the same institution may be effectively siloed from each other and from adequate, let alone rapid, communication among them.
It also needs said that the behavioral health programs writ large are not moneymakers for most institutions. Indeed, these are often significant money losers, and therefore not at all well-funded by the hospital. After all, behavioral health offers no significant procedures that leverage the financial intake of the hospital : thus,few resources are allocated to what is best considered a loss leader in the form of behavioral health treatment. Indeed, many institutions are closing their inpatient psychiatric units, and turning them into surgical or cardiac units which are far more profitable.
Another difficulty is the interface between the behavioral health and legal systems. In most states, involuntary hospitalization (when the patient who is imminently endangered has refused voluntary admission ) requires a court order based on imminent suicidality and homicidality. The police who are authorized to effect a 72 hour involuntary hospitalization are often reluctant to do so and feel out of their league in terms of assessing the clinical information presented. In fact, the presentation to the police will not be by the clinician who is recommending hospitalization, but rather by the patient him or herself. Some states like Pennsylvania require that the information be sent to an appointed delegate who is often an attorney. These attorneys often make erroneous decisions, as in the case of one of my patients who was denied involuntary commitment despite threatening to jump off of a high level to kill himself. On another occasion, the delegate refused inpatient admission when the patient actually stabbed himself. Like the police, attorneys are incapable of making the appropriate clinical decision..
Yet another factor in the rusted behavioral health mechanism stems from insurance coverage. I had worked for years in the insurance setting, charged with having to decide whether the insurance company should pay for the hospitalization at admission, and how long the hospitalization should last. The average length of stay allowed by the insurance company ranged between five and seven days, far too short a period of time for the dangerous patient (suicidal or homicidal or gravely disabled by symptoms) to fully heal. The inpatient doctor is forced to discharge patient prematurely, again, often, to an outpatient setting only, and often able to make an appointment for his patient only many weeks post discharge.These system failures can place the patient in a life and death situation.
Health insurance companies pose multiple other obstacles to good behavioral treatment. Unbeknownst to most of us, each of these companies writes specific policies regarding the coverage of all the medications on their formulary(the basket of drugs they will cover), Already, some drugs are not covered at all, or are not covered on your particular policy. Of those covered, however, the insurance company will require that the patient try and "fail" a number of other , cheaper(for the company) medications before they might authorize the better medication prescribed by your doctor.
This process applies not only to psychiatric, but also to general and specialty medications as well. This process often leads to what amounts to destructive medical care forced on the patient by his/her insurance company. Here is a case in point: Among the best medications for Bipolar disorder is ond called cariprazine, It is effective for mania, Bipolar depression, as well as mixed manic and depressive symptoms , One large health insurance company in Pittsburgh requires, however, five failures of oldwer medications before they will consider authorizing cariprazine, Moreover, these older medications are far more likely to induce major medical problems including, but not limited to, major weight gain, metabolic syndrome, type ll diabetes, pseudoparkinsonism, tremor, as well as significant sexual side effects. Insurance literally requires the patient to get worse before she may get better. In the process, the company will be requiring great amounts of the doctor<s time to do the paperwork to preauthorize the requested medication, time much better spent on direct patient care.It is important for the consumer to internalize that "health insurance" is not necessarily designed to promote health.
Finally, there being little to no communication between the outpatient doctor in the inpatient physician, and therefore little coordination between them, the inpatient psychiatrist will have access to, and often treat the inpatient with, medications that the patient cannot afford by himself out of the hospital. The inpatient physician has access to medications in the hospital that will be covered by the inpatient insurance, but these medications will be denied by the insurance company when the patient is transferred to the outpatient setting, leaving the outpatient physician to now struggle with new medications for the patient at a time of heightened vulnerability for his patient. Having just been discharged from inpatient care, the patient is placed in a highly vulnerable and potentially dangerous position. Were there adequate communication between the outpatient and inpatient doctors, they could coordinate and agree on medications that can be easily transitioned to the outpatient setting. Alternatively, were the insurance companies required to maintain all inpatient medications in the outpatient setting as well, the patient's safety would be far more assured.
How best to manage the Behavioral Health system?
First, forewarned is forearmed. Understanding the behavioral health system is a must, with its pluses and major flaws. Understanding that health insurance is first and foremost insurance and only secondarily, if at all, devoted to your health is also prerequisite.
Study the levels of care described previously. If your behavioral/emotional issues fit the outpatient level of care, ask yourself if your symptoms are primarily those related to the symptomatic syndromes noted previously: anxiety, panic attacks, fear of public spaces, other phobias, social anxiety, depression, hypomania, excessive irritability or elation, hallucinations, delusional thinking, sleep disorders, or problems with focus nd attention, These symptoms are treatable medically and should lead to seek a psychiatric evaluation primarily. Likewise, if you are unsure of your symptoms, a psychiatrist will help you rule out the need for medication treatment. When your symptoms abate, the psychiatrist can evaluate whether psychological care is nonetheless still indicated, and make an appropriate referral. If your symptoms carry no dangers, you do not suffer from the symptomatic syndromes noted, and you are able to still function in your daily life, albeit with difficulty, you may be best off seeking psychological treatment from a licensed psychologist, psychiatric social worker, psychiatric nurse or other approved counselor.
If your symptoms better match the criteria for intensive outpatient treatment or a higher level of care, you are best to go to a hospital emergency room for triage to the appropriate level of care. You should be evaluated and triaged(referred to the appropriate level of care) in a hospital emergency room. If you are acutely dangerous to yourself or others, call 911 or go immediately to the nearest hospital E.R.
Which brings us to another important understanding: The symptomatic or troubled or dangerous patient is hardly equipped, often, to make even the basic self-assessments I've suggested. It is nearly always vital for a significant other to step in assertively, help make an initial determination of the appropriate level of care, and accompany the patient to, at minimum, the initial evaluation. This function is all the more important because the patient is often likely to be ambivalent about mental health treatment, and therefore not likely to follow through with an initial evaluation. The significant other should also be available for future input to the psychiatrist or therapist as well.
Equally as important, the significant other and the patient need to understand that that they should be prepared to fill in the gaps and broken spaces the behavioral health system themselves. For instance, they may have to bring the medical history or laboratory studies to an independent outpatient psychiatrist. The patient or significant other may need to inquire about intensive outpatient or partial hospital care before a discharge is arranged, or, alternatively, research the availability of these rare programs themselves. Other research will often need to be done to gain more education than provided in session about medication side effects or ancillary programs such as ketamine or rTMS clinics.
Patients and their significant others should by all means learn about the insurance business and about their behavioral health benefits as well. In most cases, outpatient treatment, by law, requires accessibility equal to that of the medical care provided by your policy. However, insurance companies oversee inpatient treatment through managed care. They will have physicians on staff who (often rigidly) oversee the more extensive inpatient treatment, and limit it frequently to the less than one week length of stay noted earlier. The patient is not usually prepared to be discharged so quickly, and may need an additional few days to weeks. Indeed, they can be endangered by a rapid discharge. It is important at that point, especially if the patient is still or could quickly become dangerous or gravely disabled, to become a "squeaky wheel." Do not be shy here, The system is truly broke. Specifically, ask the treating doctor to file an appeal with the insurance. If still denied, the physician has at least 2 more levels of appeal to seek an overturn of the original decision, and must be encouraged to do so. (One can imagine how difficult is this role, and how time consuming. Moreover, one cn also imagine the medicolegal bind the physician finds hereself in when she is forced by the insurance, and her hospital, to discharge a patient she sees asstill endangered preaturely).
Unbeknownst to most insurance consumers, and in the fine print of their lengthy letters and policies, the patient also may appeal denial decisions through a Member Grievance. A verbal appeal to the Member Services Department may be ignored., but a Witten appeal the Member Services Department must be answered by law. Here, too, the consumer is entitled to multiple levels of appeal. Keep appealing until you get satisfaction. Word to the wise: The insurance company abhors bad PR and squeaky wheels. This is your leverage. In most cases, the final appeal level for the physician is an outside review organization required by law to do final appeals. These have no pecuniary allegiance to the insurance company and often overturn earlier denials. Finally, you may appeal to the Insurance Commission in your state, or threaten the insurance that you plan to do so.
Attaining good mental health treatment is an odyssey unto itself. Many shoals and barriers exist along the way to appropriate care. These can be broken down into two large categories: knowledge of behavioral health symptoms and knowledge of the behavioral health system. I am concerned with both sets of issues, as both serve as major weak links in the treatment chain. I have elsewhere written about the appalling lack of knowledge on the part of most individuals regarding mental health issues and mental health problems, made all the more astonishing by the evident fact that most of us are dealing with mental health issues, if not problems, 24 hours a day, seven days a week. I have argued previously for a mental health track to be included in all educational grades from kindergarten through college as a major step forward to reducing the incidence of behavioral health problems and behavioral health dangers such as suicide.
Here, however, I hope to describe how the American behavioral health system is meant to function in its pure state, and how it functions and dysfunctions in its real state. It is important for the consumer to understand the way the system should function, the ways it does not function, and what the mental health consumer should do to compensate for these systemic issues. This knowledge will help people navigate and otherwise creaking, archaic behavioral health system for themselves and their significant others.
How the Behavioral Health System Should Work
Behavioral health treatment is provided in distinct levels of care. The lowest level of care is outpatient treatment, either in the form of therapy or psychopharmacology and performed either by a psychiatrist, or a psychologist, social worker, or other behavioral health counselors who do therapy only. Therapy in this case is done anywhere from twice a week to once a month, though some psychopharmacological work is done by psychiatrists every three months for stabilized patients. Individuals who are appropriate for outpatient treatment are those who are functioning reasonably well in their daily lives, but who are suffering symptoms which nonetheless impede their full functioning, such as anxiety, depression, hypomania,; or, patients who are having difficulty in their relationships, with their psychological issues, or with their inability to cope with normal or excessive external stress. Therapy may take different forms, including psychoanalytically informed psychotherapy, behavioral therapies, cognitive behavioral therapy, interpersonal therapy, and dialectical behavioral therapy. Individuals who are appropriate for outpatient treatment pose no danger to themselves or others and, for the most part, are able to carry on their normal daily lives, though with barriers and inefficiencies stemming from their personalities and/or symptoms.
It is important to understand the difference between psychiatric treatment and psychological treatment, though some psychiatrists still practice both. For the most part, psychiatrists currently focus their attentions primarily on conditions which produce symptoms amenable to psychopharmacology, that is to say, psychiatric medications. These conditions include all the anxiety disorders, depression, bipolar disorder, some schizophrenias, obsessive-compulsive disorder, eating disorders, autistic disorders, posttraumatic stress disorder, and attention deficit hyperactivity disorder. Psychologists, psychiatric social workers, counselors, and some psychiatrists also participate in the psychotherapies noted earlier. These therapies deal with the interpersonal problems, psychological issues, and environmental stressors which are generally not amenable to medical-psychiatric treatment. They are, however, amenable to the variety of talking treatments specified previously. It is important to understand the symptomatic syndromes treated by psychiatrists often worsen the co-occurring psychological, interpersonal, and environmental issues that are comorbid. Ideally, then, all behavioral health patients should be evaluated first and foremost by a psychiatrist to rule out the existence of symptomatic syndromes(collections of symptoms) which can be treated more quickly and efficiently by the psychiatrists medications. Symptoms associated with the psychiatric syndromes are truly the "low hanging fruit" of mental health treatment
To say this from the opposite point of view: One often sees patients who are suffering significant anxiety, depression, and bipolar symptoms who, not knowing where to turn for treatment, naturally seek out a talking therapist first. Two years of treatment may go by and little may have been accomplished by talking treatment alone, so long as the symptomatic syndromes are left untreated medically. Only then may the therapist suggest that it would be useful to seek a consultation from the
psychiatrist. The patient has lost two years of potentially greater functionality by entering the behavioral health system at the wrong point.
Above the outpatient level of care is the intensive outpatient setting. Individuals deemed appropriate for this setting are those whose symptoms are sufficiently intense that they cannot successfully master their activities of daily living. These might include the inability to take care of their children, take medications for diabetes properly, maintain employment, bathe and feed themselves. Generally, appropriate individuals are not a danger to themselves or others when admitted to the intensive outpatient setting. In practice, intensive outpatient treatment consists of three visits per week to the intensive outpatient program, usually two to three hours per visit. Treatments include medication therapy, individual therapy, group therapy, and general monitoring for safety concerns. Therapist of various specialties man these programs, including a psychiatrist for the medical/psychiatric care. At times, intensive outpatient programs are subdivided into those which treat borderline personality disorders, obsessive-compulsive disorders, depressive disorders, etc. At other times the intensive outpatient program consists of a mix of diagnoses rather than the sub-specializations.
A yet higher level of care is the partial hospital program. Here, the patient is not only unable to function in terms of his or her activities of daily living, but also poses a subacute danger to himself or others. This is a technical way of indicating that the patient has some thoughts of suicide, perhaps some thoughts of hurting others, but is not considered an imminent danger to carry out any of these acts, which remain at the level of contemplation only. These programs are difficult to find, but also manned by a variety of behavioral health specialists as well as a psychiatrist. The program length is all day five days a week, but the patient is home in the evenings and on the weekends. There is much careful monitoring done for suicidality and homicidality, as would be expected for individuals who are having current thoughts of harming themselves or others. It would be incumbent upon the therapist and the patient to monitor these thoughts and prevent them from leading to the point of action.
The highest level of behavioral healthcare is the inpatient setting. This program is reserved for patients who are acutely suicidal, acutely homicidal, or for those patients whose symptoms are so severe that they pose an imminent danger to their own health or welfare. An example of the last category might be an individual with schizophrenia who is not in any sense physically threatening to self or others but was unable to manage taking ahis psychiatric or medical medications appropriately, to the point of putting his health in danger. These hospitalizations take place in a psychiatric unit attached to a large General Hospital. Whereas in years past a psychiatric hospitalization might have lasted anywhere from two weeks to several months, current managed care practiceshave limited these hospitalizations to an average length of stay of approximately 5 to 7 days nationally.
For the system to function smoothly and effectively there needs to be seamless and timely coordination amongst the various levels of care. This would also imply that all levels of care should be, optimally, provided within the same institution. In addition, there needs to be rapid and clear communication channels amongst the various treatment settings. For instance, if a patient were to require immediate hospitalization from the outpatient setting, the outpatient physician should be able to contact the inpatient department so that the hospitalization be effected quickly and safely. After all, the individual is considered to be an imminent danger to himself or others and needs immediate monitoring and protection. In a reverse fashion, patients who are being discharged from an inpatient setting need to be able to be transitioned quickly to a partial hospital setting or to an intensive outpatient setting. This is especially important because the act of discharge is fraught with multiple dangers. For one, it often takes many weeks to get an outpatient appointment with a psychiatrist and with the therapist. More importantly, however, the transition from inpatient treatment is associated with a high level of suicidal behavior. In fact, one of the most significant risk factors for suicide is the week post hospitalization. The patient, after all, is leaving a protected and secure environment, and is being thrust back into the selfsame arena where he or she may have experienced stressors which led to the hospitalization. For this reason, it is imperative that best practices include a discharge to a partial hospital or intensive outpatient setting for all inpatient discharges.
In order for patients to transition easily from one setting to another, there would need to be ample funding for appropriate staff and ample spaces for the new patient to fit into all the settings.
How does the behavioral health system function in practice?
For most institutions, the de facto behavioral health program falls far far short of the ideal, and is woefully inadequate. It is for this reason that patients, and especially significant others who are attending to the patient, need to understand the barriers and pitfalls they will be encountering in navigating through this arcane system. In fact, the significant others of necessity will need to be advocates for the patient and help smooth the transitions when the system fails them.
In point of fact, most institutions do not provide all the necessary levels of care. A typical large hospital may have an outpatient department, a small inpatient unit, and occasionally intensive outpatient program. It is very rare to see all four levels of care within the same institution. In fact, it is quite rare to find a partial hospital setting anywhere. Related to this, Medicare pays for outpatient and inpatient but not necessarily for both intensive outpatient and partial hospital treatment. Moreover, the co-pays required for intensive outpatient can be quite burdensome to financially strapped individuals, as they are paying an outpatient co-pay three times per week. This financial barrier often blocks the patient from seeking or accepting intensive outpatient care.
In terms of the treatment venues, the outpatient treatment may be taking place in a private practice setting having no communication lines whatsoever with the large institution that may provide the intensive outpatient program or inpatient programs. Unfortunately, even programs housed within the same institution may be effectively siloed from each other and from adequate, let alone rapid, communication among them.
It also needs said that the behavioral health programs writ large are not moneymakers for most institutions. Indeed, these are often significant money losers, and therefore not at all well-funded by the hospital. After all, behavioral health offers no significant procedures that leverage the financial intake of the hospital : thus,few resources are allocated to what is best considered a loss leader in the form of behavioral health treatment. Indeed, many institutions are closing their inpatient psychiatric units, and turning them into surgical or cardiac units which are far more profitable.
Another difficulty is the interface between the behavioral health and legal systems. In most states, involuntary hospitalization (when the patient who is imminently endangered has refused voluntary admission ) requires a court order based on imminent suicidality and homicidality. The police who are authorized to effect a 72 hour involuntary hospitalization are often reluctant to do so and feel out of their league in terms of assessing the clinical information presented. In fact, the presentation to the police will not be by the clinician who is recommending hospitalization, but rather by the patient him or herself. Some states like Pennsylvania require that the information be sent to an appointed delegate who is often an attorney. These attorneys often make erroneous decisions, as in the case of one of my patients who was denied involuntary commitment despite threatening to jump off of a high level to kill himself. On another occasion, the delegate refused inpatient admission when the patient actually stabbed himself. Like the police, attorneys are incapable of making the appropriate clinical decision..
Yet another factor in the rusted behavioral health mechanism stems from insurance coverage. I had worked for years in the insurance setting, charged with having to decide whether the insurance company should pay for the hospitalization at admission, and how long the hospitalization should last. The average length of stay allowed by the insurance company ranged between five and seven days, far too short a period of time for the dangerous patient (suicidal or homicidal or gravely disabled by symptoms) to fully heal. The inpatient doctor is forced to discharge patient prematurely, again, often, to an outpatient setting only, and often able to make an appointment for his patient only many weeks post discharge.These system failures can place the patient in a life and death situation.
Health insurance companies pose multiple other obstacles to good behavioral treatment. Unbeknownst to most of us, each of these companies writes specific policies regarding the coverage of all the medications on their formulary(the basket of drugs they will cover), Already, some drugs are not covered at all, or are not covered on your particular policy. Of those covered, however, the insurance company will require that the patient try and "fail" a number of other , cheaper(for the company) medications before they might authorize the better medication prescribed by your doctor.
This process applies not only to psychiatric, but also to general and specialty medications as well. This process often leads to what amounts to destructive medical care forced on the patient by his/her insurance company. Here is a case in point: Among the best medications for Bipolar disorder is ond called cariprazine, It is effective for mania, Bipolar depression, as well as mixed manic and depressive symptoms , One large health insurance company in Pittsburgh requires, however, five failures of oldwer medications before they will consider authorizing cariprazine, Moreover, these older medications are far more likely to induce major medical problems including, but not limited to, major weight gain, metabolic syndrome, type ll diabetes, pseudoparkinsonism, tremor, as well as significant sexual side effects. Insurance literally requires the patient to get worse before she may get better. In the process, the company will be requiring great amounts of the doctor<s time to do the paperwork to preauthorize the requested medication, time much better spent on direct patient care.It is important for the consumer to internalize that "health insurance" is not necessarily designed to promote health.
Finally, there being little to no communication between the outpatient doctor in the inpatient physician, and therefore little coordination between them, the inpatient psychiatrist will have access to, and often treat the inpatient with, medications that the patient cannot afford by himself out of the hospital. The inpatient physician has access to medications in the hospital that will be covered by the inpatient insurance, but these medications will be denied by the insurance company when the patient is transferred to the outpatient setting, leaving the outpatient physician to now struggle with new medications for the patient at a time of heightened vulnerability for his patient. Having just been discharged from inpatient care, the patient is placed in a highly vulnerable and potentially dangerous position. Were there adequate communication between the outpatient and inpatient doctors, they could coordinate and agree on medications that can be easily transitioned to the outpatient setting. Alternatively, were the insurance companies required to maintain all inpatient medications in the outpatient setting as well, the patient's safety would be far more assured.
How best to manage the Behavioral Health system?
First, forewarned is forearmed. Understanding the behavioral health system is a must, with its pluses and major flaws. Understanding that health insurance is first and foremost insurance and only secondarily, if at all, devoted to your health is also prerequisite.
Study the levels of care described previously. If your behavioral/emotional issues fit the outpatient level of care, ask yourself if your symptoms are primarily those related to the symptomatic syndromes noted previously: anxiety, panic attacks, fear of public spaces, other phobias, social anxiety, depression, hypomania, excessive irritability or elation, hallucinations, delusional thinking, sleep disorders, or problems with focus nd attention, These symptoms are treatable medically and should lead to seek a psychiatric evaluation primarily. Likewise, if you are unsure of your symptoms, a psychiatrist will help you rule out the need for medication treatment. When your symptoms abate, the psychiatrist can evaluate whether psychological care is nonetheless still indicated, and make an appropriate referral. If your symptoms carry no dangers, you do not suffer from the symptomatic syndromes noted, and you are able to still function in your daily life, albeit with difficulty, you may be best off seeking psychological treatment from a licensed psychologist, psychiatric social worker, psychiatric nurse or other approved counselor.
If your symptoms better match the criteria for intensive outpatient treatment or a higher level of care, you are best to go to a hospital emergency room for triage to the appropriate level of care. You should be evaluated and triaged(referred to the appropriate level of care) in a hospital emergency room. If you are acutely dangerous to yourself or others, call 911 or go immediately to the nearest hospital E.R.
Which brings us to another important understanding: The symptomatic or troubled or dangerous patient is hardly equipped, often, to make even the basic self-assessments I've suggested. It is nearly always vital for a significant other to step in assertively, help make an initial determination of the appropriate level of care, and accompany the patient to, at minimum, the initial evaluation. This function is all the more important because the patient is often likely to be ambivalent about mental health treatment, and therefore not likely to follow through with an initial evaluation. The significant other should also be available for future input to the psychiatrist or therapist as well.
Equally as important, the significant other and the patient need to understand that that they should be prepared to fill in the gaps and broken spaces the behavioral health system themselves. For instance, they may have to bring the medical history or laboratory studies to an independent outpatient psychiatrist. The patient or significant other may need to inquire about intensive outpatient or partial hospital care before a discharge is arranged, or, alternatively, research the availability of these rare programs themselves. Other research will often need to be done to gain more education than provided in session about medication side effects or ancillary programs such as ketamine or rTMS clinics.
Patients and their significant others should by all means learn about the insurance business and about their behavioral health benefits as well. In most cases, outpatient treatment, by law, requires accessibility equal to that of the medical care provided by your policy. However, insurance companies oversee inpatient treatment through managed care. They will have physicians on staff who (often rigidly) oversee the more extensive inpatient treatment, and limit it frequently to the less than one week length of stay noted earlier. The patient is not usually prepared to be discharged so quickly, and may need an additional few days to weeks. Indeed, they can be endangered by a rapid discharge. It is important at that point, especially if the patient is still or could quickly become dangerous or gravely disabled, to become a "squeaky wheel." Do not be shy here, The system is truly broke. Specifically, ask the treating doctor to file an appeal with the insurance. If still denied, the physician has at least 2 more levels of appeal to seek an overturn of the original decision, and must be encouraged to do so. (One can imagine how difficult is this role, and how time consuming. Moreover, one cn also imagine the medicolegal bind the physician finds hereself in when she is forced by the insurance, and her hospital, to discharge a patient she sees asstill endangered preaturely).
Unbeknownst to most insurance consumers, and in the fine print of their lengthy letters and policies, the patient also may appeal denial decisions through a Member Grievance. A verbal appeal to the Member Services Department may be ignored., but a Witten appeal the Member Services Department must be answered by law. Here, too, the consumer is entitled to multiple levels of appeal. Keep appealing until you get satisfaction. Word to the wise: The insurance company abhors bad PR and squeaky wheels. This is your leverage. In most cases, the final appeal level for the physician is an outside review organization required by law to do final appeals. These have no pecuniary allegiance to the insurance company and often overturn earlier denials. Finally, you may appeal to the Insurance Commission in your state, or threaten the insurance that you plan to do so.
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