1  

Psychiatry/Mental Health Lown Institute RightCare Alliance Council Mission Statement

Many patients who need care often can’t or don’t get it. Underuse is caused by various reasons, including stigma, scarce resources, the usual health insurance industry practice of “carving out” mental health benefits, and the fact that health care organizations often restrict access to mental health care given the low reimbursement rates for mental health services. At the other extreme, many who do not need mental health treatment are receiving it nonetheless. Such care may not only not help patients but in fact harm them. Overuse of mental health care is caused by several things: physicians practicing defensive medicine, an ever-expanding list of psychiatric conditions and diagnoses which cause those without diagnosable conditions to consider themselves ill, and aggressive marketing tactics of the pharmaceutical industry. We are dedicated to eliminating obstacles to care for those patients who need it and correcting what we see as the over-selling and overuse of psychiatric treatment. We believe that achieving these goals will both serve the needs of our patients and also result in greater job satisfaction for practicing clinicians.

Current data about the extent and societal costs of psychiatric illness in the US:

• Mental health disorders are the leading cause of disability in the U.S.

• 1 in 5 U.S. adults have a mental illness problem

• Less than 40 percent of affected adults will receive any mental health services (Murray,

Abraham, Ali, et al, 2013 and Mathers, Fat, and Boerma, 2008).

• The estimated cost of major depression alone in the US was an estimated $210 billion in

2010. (Greenberg et al, 2015).

• Inadequate treatment contributes to homelessness, lost productivity, suicide, high rates of

incarceration, and spillover costs to other parts of the health system.

• Our prison system is our nation’s largest provider of mental health services

• Four million children and adolescents in this country suffer from a serious mental

disorder that causes significant functional impairments at home, at school and with peers.

  2  

• In any given year, only 20 percent of children with mental disorders are identified and

receive mental health services (U.S. Public Health Service, 2000).

• Disorders in youth can have life-long deleterious effects.

Obstacles to obtaining appropriate psychiatric care:

• Drastic cuts in funding for housing and care of the severely mentally ill after

deinstitutionalization essentially criminalized mental illness, with many individuals either

imprisoned or homeless.

• Demand for psychiatric services outstrips supply (Weiss et al, 2012)

• Emergency departments have become de facto psychiatric wards, with many psychiatric

patients boarding for days prior to receiving appropriate placement (American College of

Emergency Physicians, 2008).

• Due to the inadequate number of psychiatrists and the limited training for psychiatrists in

collaborative care models, primary care physicians provide roughly 2/3 of all care for

depression and other common psychiatric and behavioral disorders without the time or

resources needed for careful diagnosis and treatment.

• The Affordable Care Act has done little to improve access or change the predatory

practices of insurers that single out psychiatric patients for special scrutiny

• Insurers aggressively “manage” mental health care and require prior authorization for

inpatient and outpatient psychiatric treatment more frequently than for any other medical

specialty (Funkenstein et al, 2013)).

• Insurers stringently limit contracted providers and maintain lists of supposed in-network

providers that are replete with wrong numbers and/or providers who are not accepting

patients (Malowney et al, 2014).

• Reimbursement for psychiatric care is often so low that health care facilities frequently

make it as difficult as possible to access whatever services that they do provide.

  3  

• Lack of treatment options often means that law enforcement officers are the first

responders to those with mental illness, which can possibly lead to shootings and

imprisonment

• Under-treatment and lack of access leads patients to worsen, creating greater need in both

the short term and long term.

• Increased burden of documentation and billing drains provider resources and leads to

greater use of psychiatric medications as a “quick fix.”

• 80 percent of all psychiatric medications are prescribed by non-psychiatric physicians,

often after a 7 minute visit.

• Seven percent of Americans are now addicted to a legal psychotropic drug, with

prescription drug abuse a bigger problem than illicit drug use. (Allan Frances, Saving

Normal, New York: William Morrow, 2013)

• Over the last several years big pharma including Johnson & Johnson, Pfizer, Eli Lilly and

others--has paid over $10 billion in fines and settlements for off-label promotion of drugs

and fraudulent branding.

• Each DSM deems an ever-enlarging list of behaviors to be pathological.

• The pharmaceutical industry permeates psychiatry and peddles newer, more expensive

drugs that often have little real benefit compared to older ones.

• 70 percent of the psychiatrists who authored the DSM 5 had ties to the pharmaceutical

industry, and every new diagnosis offers a new avenue for the pharmaceutical industry to

pitch it wares.

• The diagnosis of many psychiatric conditions has increased dramatically over the last 2

decades resulting in dramatic increases in prescribing of medications.

Right care changes needed in psychiatry:

• A rational, need-based, evidence-based system of treatment that addresses inequities in

mental health care but does not overreach and over-treat.

  4  

• Alter psychiatry education to promote the use of generics and older drugs when newer

drugs—despite their glamor and potential promise—are not actually better than older

ones.

• Actively promote education in psychiatry about becoming stewards of societal resources.

• Pursue genuine parity for mental illness, including eliminating the requirement for

obtaining prior authorizations prior to admitting patients or for other needed care.

• Foster research in evidence based practice.

• Authors of future editions of the DSM should not have had received any money from the

pharmaceutical industry for at least 3 years prior to their work on the DSM and should

pledge not to do so for at least 3 years after publication. (Department chairs whose

departments receive pharmaceutical industry funding will be prohibited form serving on

any DSM committee.)

• Medically necessary services will not be subject to limits on treatment, whether inpatient

or outpatient.

• Psychiatric medications should be covered fully, without co-pays or deductibles.

• Treatment for substance use disorders would be included along with all other forms of

psychiatric care.

Conclusion:

We believe that implementing our suggestions for reform would go a long way to ensuring that patients receive needed care but are not subjected to unnecessary, revenue generating, treatment. We also believe that the practice environment of psychiatrists would improve tremendously were these recommendations implemented.