Healthcare: ‘Too important to be left to politicians’

Things in the behavioral health world aren’t perfect, but they are better than they used to be, according to Jeffrey A Lieberman, MD, president of the American Psychiatric Association (APA).

After years of work as a psychiatrist taking care of patients and conducting clinical research, Lieberman recently switched gears and began looking into issues relating to policy and administration. He said this shift is due mainly to his current role at the APA and also his role as chairman of psychiatry at Columbia University College of Physicians and Surgeons.

“The reason that I’ve seen those as desirable things to transition to and learn about is because it’s really critical that we be knowledgeable, strategic, and proactive at this point in time given where our country is at in terms of its policies and healthcare,” Lieberman explained at the 2014 National Association of Psychiatric Health Systems (NAPHS) annual meeting. “And, as anybody who spends any time in Washington or pays attention to Washington knows, you can’t have a tremendous amount of confidence in the politicians and policy makers to make the right decisions. Healthcare is too important to be left to the politicians.”

He feels that the problem with the current state of healthcare is that the United States hasn’t yet decided “how it wants to finance healthcare.” The nation, he asserts, must decide whether healthcare is a right or a commodity.

“If it’s a commodity then you get what you pay for and if it’s a right, then everyone gets it but the question is how much are you prepared to spend?”

“Nobody knows how this is going to end up,” he continued. “They just know that something has to happen because the current method is not sustainable.”

On the topic of the Affordable Care Act (ACA), Lieberman acknowledges that there are various opinions on the subject and shared his own thoughts about it: “My opinion is that it’s a terrible piece of legislation which I don’t pretend to even comprehend much of. On the other hand, I applaud the President for getting something done because something had to be done. We can’t live in this kind of alter universe of denying the fact that we have to figure out how we’re going to pay for healthcare.”

The stepchild of healthcare

Because of the “government policy ineptitude,” Lieberman said that the healthcare system has become sick, and when that happens, mental healthcare gets critically ill. “We suffer more,” he explained. “That’s been our lot in life.”

He said that historically, psychiatry has been the stepchild of healthcare for several reasons:  Lacking hard outcomes to use to gather quality metrics, and not fully being able to understand the etiologies/mechanisms of many of the treatments – “we just know that they work.”

Even though mental healthcare may be “the sibling who’s disparaged, the one that the others make jokes about,” it certainly is a vital part of the family that the others don’t want to or can live without, he explained.

He lamented the fact that some neuroscience professionals – Tom Insel and Steve Hyman – have been very hard on the field due to the lack of science-based treatments. He spoke of his colleagues saying things like: “The field of psychiatry doesn’t know anything” and “We can’t treat anybody” and “We need to do better and throw out everything we know in terms of science to start over.” While he believes such sentiments are very unfair, they do represent real frustrations with the current state of psychiatry.

He said that the reality is that psychiatry – in terms of its therapeutic capability, the size of the population it treats, and the economic burden on the country and on the world measured by world bank metrics (disability adjusted life years) – is very consequential.

While the field may not yet have hammered down what exactly causes the illnesses it is treating and the specific mechanisms and actions of how they’re working, the treatments are generally effective. And although many give mental healthcare a hard time, Lieberman defended it by saying that it has made much more progress than its sister discipline, neurology.

For disorders such as Huntinton’s Disease and Amyotrophic lateral sclerosis (ALS), he suggested that there are no true treatments at this point. The mental health field gets much “unwarranted criticism because we’ve had a harder time learning, understanding, and explaining.” The reason it’s been hard, according to Lieberman, is because all of the work in the field deals with the brain – an organ that is “vastly more complex than any other organ in the body.”

He explained that if you took a small biopsy of a kidney or a liver and examined it under a microscope, it would look the same as any other part. However, the brain has more cells (100 billion cells), more connections (30 trillion synaptic connections), and each part is different from the next.

When the brainwork was divided into neurosurgery, neurology, and psychiatry, the other areas took the “easy stuff,” said Lieberman. “What we got were the most highly involved functions in the animal kingdom. There’s no animal model for many of these. There’s nothing to be apologetic about.”

‘The best place to be mentally ill’

Lieberman believes that the United States is the best place in the world to be mentally ill in terms of stigma, discrimination, social attitudes. While it’s not perfect, the public is fairly open and accepting of these issues being discussed and treated. Tragic and unwanted events that are caused by individuals such as Adam Lanza and James Holmes have a hint of positive to them as they bring attention to issues and spark positive outcomes to occur.  

For example:

• Congressman Tim Murphy who has recently emerged as “a new champion of mental illness in healthcare” has introduced new legislation which could be helpful,
• Patrick Kennedy left congress and “sort of assumed this public spokesperson’s role,” and,
• the final rule of parity act was pushed through in large part with contributions from APA and Health and Human Services (HHS).

He touched on the immense costs of mental healthcare and noted that the country doesn’t focus as much (in terms of money) on mental healthcare as it does on areas such as cardiovascular disease or cancer. “As the morbidity and mortality of these are reduced, the proportionate costs for mental illness increase,” Lieberman explained. “So, we’re going to be the leader in terms of public enemy number one or public health cost driver number one.”

The solution, he said, is to figure out how to the country is going to constitute its healthcare system in light of the need to do it in a cost-effective way. This includes effecting models of service delivery and determining the best means of reimbursing in terms of financing schemes and levels of reimbursement.

Changes ahead

The hardest obstacle that lies ahead for himself, the APA, and his colleagues, according to Lieberman, is that everyone is going to have to realize that their job descriptions have to change.

He believes there are three populations, or buckets, of patient populations:

• Individuals who are chronically or persistently mentally ill and are treated through psychiatry or mental healthcare facilities.
• Individuals who have psychiatric co-morbidity, who are associated with medical or surgical co-morbidities – a big cost driver for hospitals and health systems.
• Individuals who may have milder psychiatric disorders but crises in life cause them to seek brief treatment.

Over the years, various models have been discussed but must be developed more in order to address these differing needs. The model that’s most widely acknowledged and publicized at this point is the integrated care model.

In such a model, psychiatrists aren’t the only ones providing care. It is a team-based care system in which other allied health and mental health professionals are involved. “Psychiatrists won’t do some of the things with patients that they previously have done,” he explained. “But they’re not going to just sit in their offices writing prescriptions for 100 people per day either.”

If the system were to evolve to a model such as this, individual responsibilities would have to change and questions about payment would need to be answered. For example, who is responsible for payment in an integrated care system? How will reimbursement function for different payment schemes to the providers whether it’s coming out of fee-for-service, managed care, or a capitated service?

“We just need to be willing to take what historically has been a healthcare disparity, a disenfranchised group of illnesses, and we need to be willing to substantially reconfigure the way we see our roles and the kind of services we provide,” Lieberman said.

Beyond that, he said that the next opportunity in this process is to enact a public health approach to mental healthcare. As far as screenings go, they would need the measures and the ability to take them out of healthcare settings and into the community, schools, or the workplace. People are generally sensitive about someone “pointing the finger at them and labeling them or their children as having a mental illness.” He would love to see these aspects of the field change.

Unsure of when the changes will happen, but certain that changes will occur in the field, he noted that if these alterations aren’t made by those in the field, they’ll be “provided for us and that could be disastrous."

“I hope this will be an inflection point for our field that we will look back at and say that we really made the most of that opportunity.”