Should I teach them the right way to care for patients?

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Allow me to digress today and share from one of my "tent-making" jobs that provides my family with the financial support necessary for me to spend some of my time serving in the leadership of our ministry.

In addition to my unpaid work with Key, I have three jobs for which I receive financial compensation. One is my child and adolescent psychiatry practice. Another is the teaching position I hold at the medical school from which I graduated. The third is a consulting position I hold with a large child and adolescent community mental health agency in a county approximately an hour from where I live.

In my position with the mental health center, I'm implementing a redesign of the system through which families of children and teens with mental health conditions access psychiatric care. The plan utilizes available child and adolescent psychiatry resources to expand the capacity of primary care practices to identify and treat youth with serious mental health conditions, and emphasizes interdisciplinary training of early-career mental health professionals.

My work with the mental health center has probably been the most gratifying of my three paying jobs over the past year. We've hired a wonderful new medical director with board certifications in three different specialties, including child and adolescent psychiatry along with four bright and highly motivated nurse practitioners newly licensed over the last year. We've more than doubled the number of kids seen by the agency's medical department over the last year and plan to quadruple our service capacity by next summer.

A large part of my job involves providing training to the medical and psychological staff of the agency and the legally required collaboration with our nurse practitioners. The training and collaboration is essential to the success of the plan. We want to train our clinicians in the most current, evidence-based practices before they've developed bad habits or experienced a work situation in which they were required to cut corners. The kids served by our mental health agency are incredibly complicated. Those who are referred to medical services more often than not have experienced significant trauma. Very few come from intact families. Their families of origin are often characterized by multigenerational histories of serious mental illness and substance use.

This past Wednesday, a very experienced nurse who helps provide care coordination for kids served by our clinic pulled me aside and told me she had to counsel one of our nurse practitioners to "don't listen to Dr. Steve." Here's what happened...

I'd explained the process we use to initiate treatment with ADHD medication. We typically start children on the lowest dose of medication available and increase the dose on a weekly basis (the American Academy of Pediatrics practice guidelinessuggest every three to seven days) in the absence of significant side effects until the child's symptoms have resolved. By following the recommended procedure, our clinician was creating an administrative nightmare for themselves and for our agency.

Our care coordinator arrived that day to eight "prior authorization" requests from the insurance companies responsible for managing benefits for kids enrolled in Ohio Medicaid and private insurance. Basically, the insurance companies demand a review process that can take an hour or longer to complete in which a staff person from our agency has to justify the need for the prescription written by their psychiatrist or prescriber before the family is permitted to get the medication. The prior authorization process can take longer than the standard amount of time some insurance companies allocate for the child's complete evaluation. The process is likely required whenever a new patient is seen, when medications are changed, or in some instances, when the dose of a medication is adjusted.

By following the proper procedure, our clinician was generating an unsustainable volume of prior authorization requests, most of which represent an exercise in futility. From what our staff explained to me, the typical procedure among the insurance companies that cover the kids seen in our clinic is to approve one prescription every thirty days for thirty pills from a highly restricted medication formulary. Spending the time on a prior authorization or appeal represents a waste of limited resources. Increasing the dose after a week means the family will run out of medicine ten days early with no recourse to get more.

Another conversation overheard in the hallway later in the morning. One of our prescribers wanted to conservatively increase the dose of a serotonin reuptake inhibitor by half a pill per day for a child they were treating for anxiety. Conservative dosing is especially important in our kids because those with trauma or other conditions impacting self-control are very susceptible to problems with impulsivity as the dose of these medications are increased. They were informed the dosing strategy would be impossible because their patient's insurance company would refuse to pay for more than thirty pills per month for a product that would typically cost less than $10/month at a local pharmacy.

I found myself wondering whether the day represented a sign from God that it might be time for me to move on to a different type of work. I've found myself exhibiting truly unhealthy displays of anger when some pharmacy benefit manager gets in the way of a kid under my care getting access to medication that I think they need. I said a few things this past Wednesday that were unbecoming of an elder and ministry leader  (use your imagination!) that would have likely earned me a one way ticket to anger management class if I were working in a big, bureaucratic system. Later in the day, I was looking up a research paper for one of our clinicians on an older drug that hasn't been used in any significant way for the last ten years for which he struggled to find information online. This older drug was the only covered alternative to two earlier generic forms of Concerta that had already been found by the FDA to be inferior to the original drug, but hadn't been removed from the market because they weren't clearly unsafe.

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I could never work as a clinician at the mental health center I described. I need far more time than the insurance companies allow to do a thorough and complete evaluation, especially with complicated kids. The burden of having to collect clinically irrelevant information required by the electronic record and the distraction of having to type answers into a computer while talking to patients wouldn't leave me with the cognitive capacity to do my best for my patients. But the biggest problem I'd face is knowing that the kids I'd be treating would be getting a lower standard of care than they could. They'd wait longer to get better, and they might be exposed to a greater risk of side effects in the process. Our agency doesn't have the money to hire the staff necessary to fight the system. Following the redesign of our state's public mental health system, we get paid less per hour for providing psychiatric care than we did when I served as the agency's Medical Director twenty years ago.

I need to get to work on the core of the training we'll be giving our young clinicians over the course of this year, and I have a dilemma. Do I train them in the best way I know how to take care of the kids in their care, or do I tell them what they'll need to know to give kids the level of care their insurance company is willing to pay for and to go home at night with a clear conscience?

It's getting harder and harder to sustain the level of care we offer through our practice. We've declined contracts with any insurance companies for many years because the terms of those contracts would essentially necessitate us to provide "assembly-line" care. Doctors are compensated very well under insurance for seeing three, four or more patients per hour and very poorly for longer appointments with their patients. Much to the surprise of my residents and fellows, I don't get "rich" running a practice like ours. I made less money last year than I did in my first year out of training in 1991. Given the huge increases in in durance premiums and deductibles in recent years, fewer and fewer families have the resources to access our services outside their insurance plans, and we don't have the resources to have a staff person available six days per week to run interference with their pharmacy benefit managers. It's becoming impossible for a small practice like ours to survive that seeks to provide thoughtful and personalized care while hiring the army of support staff necessary for dealing with pharmacy benefit managers and the record-keeping demands resulting from billing regulations.

I wonder if there's any correlation between the rise in suicide rates and the decline in access and availability of mental health care in this country and the rise of insurance companies and pharmacy benefit managers empowered by all levels of government to hire high school graduates to micromanage the work of medical professionals with many years of training and experience?
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Are you a pastor or ministry leader searching for resources to better understand how to support children, adults or families affected by mental illness in your church or in your community? Check out Key Ministry's Mental Health Resources page, containing links to video, articles and topical blog series designed to help you minister with persons with common mental health conditions. Also available through the website are a free, downloadable mental health ministry planning tool designed to accompany Mental Health and the Church, along with links to recommended books, like-minded mental health ministry organizations, relevant researchsermonsaddressing mental illness, social media resourcesand a compilation of storiesfrom families affected by mental illness.