The Greatest Hits of 2014?

[[{"type":"media","view_mode":"media_crop","fid":"30546","attributes":{"alt":"Psychiatry in review","class":"media-image media-image-right","id":"media_crop_3442444178766","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"3207","media_crop_rotate":"0","media_crop_scale_h":"171","media_crop_scale_w":"200","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"float: right;","title":" ","typeof":"foaf:Image"}}]]EDITORIAL

Because December is the time of year when all kinds of “top 10” lists are promulgated, I had planned to make this month’s column about the best 10 advances in psychiatry during 2014. While some things changed for the better for our patients and their families-and our profession-I’ve been having a hard time with my list.

The new coverage for psychiatric care, and the additional requirement for coverage for substance abuse services as part of the Affordable Care Act (ACA), has brought improved access to care to millions of people. In my own university clinic, I recently saw a man who had been severely impacted by the acute onset of a significant psychiatric illness 5 years ago. He had been given a prescription from his primary care physician but told me it had not helped. When I asked him why he had not asked us for an appointment sooner, he reached into his pocket and pulled out a Medicaid card. He said he had not previously been eligible for Medicaid, but that he was now as a result of our state’s decision to expand Medicaid under the ACA. He knew, he said, that coverage for the kind of care he needed, both medication and psychotherapy, would not have been available to him until now.

While we would certainly have seen this patient (about 40% of our clinic patients had no source of re­imbursement historically), the number of such patients we have been able to treat has been severely lim­ited. But with almost 15% of our metro area population newly eligible and enrolled in Medicaid following Kentucky’s decision to expand Medicaid under the ACA, our ability to treat more patients has been helpful for those we had no time to see previously because we were functioning at capacity given our costs and reimbursement.

On the other hand, Medicaid used to pay us comparably to other reimbursers. Under the new system, with all Medicaid mental health now in a managed care system, Medicaid is one of our worst sources of payment. This means that while our clinic can better cover our costs, private practitioners are little more willing to accept Medicaid patients into their practices. Obviously, in states that did not expand Medicaid, patient access to care is the same as it always was.

So, is the ACA implementation a hit or a miss for our patients and our colleagues? Unfortunately, it depends on who you ask. And, many other practice changes over the past year or so have not even been that positive. The ACA requirement for the use of an electronic health record has been at best a mixed blessing. Ideally, the availability of a patient’s health records across systems will be a wonderful thing for better care, with all clinicians involved with a patient having access to all of his or her medical records.

Furthermore, the ability to analyze population-based data should eventually allow advances in ascertaining best clinical practices. But, that ideal is a long way off. In our medical center, among the 5 hospitals and our university physicians group, there are at least 4 different EHR systems in use, and none can access information about a patient if it’s located in another system. Nor can any of them access our VA hospital records.

The ideal future includes having a system that is user-friendly, not overly time consuming to use, and one that has a template specifically geared to psychiatric practice rather than trying to pigeonhole a psychiatric note into a template developed so every physician could use it. Dermatologists have a record specifically designed by their national association to meet the EHR needs of their members, but no such system has been developed for psychiatrists.

It is not only the mechanics of the system that are problematic. We have found that the system’s cumbersome nature and the time required to use it have clearly reduced psychiatrists’ productivity, and our EHR is not much different from any other system currently available. Most important, the need to enter information into the record during a patient session has definitely had an impact on the way we can listen to our patients and on the nature of our therapeutic alliance.

Other changes have occurred over the past year or two that also have impacted practice. As one more example, the changes in CPT codes-especially the separation of E&M codes and psychotherapy codes, and the changes in documentation requirements for various E&M codes-have almost made it seem that one has to be a computer programmer to find the right code. I’ve felt this was such a widespread problem that in Psychiatric Times we’ll soon have the first of several articles that we hope will help psychiatrists more precisely determine the most appropriate billing codes.

As should be obvious, I couldn’t make a top 10 list (though I do have a few subtle references to rock and roll hits in this column). While our research continues to produce ever-increasing knowledge about the structure and function of the brain, our practice armamentarium has changed very little this year. It still appears we are years away from having an etiologically based diagnostic system, and further still from developing treatments specifically targeted to those etiologies. But by far the main impediment to delivering excellent care is that we persevere within a fragmented and underfunded system with treatments that are still heavily pathology-focused. Prevention- and recovery-focused care are still modest aspects of our over-all system-because they are hardly reimbursed.

Because it seems the system of care requires such a major overhaul, we asked Allen Frances to construct his own “top 10” list . . . but in his case, the top 10 changes required to fix our mental health care system. Allen, not surprisingly, rose to the task and invited a number of prominent colleagues to contribute their own perspectives on the top 10 needed changes. In this issue, you’ll see Allen’s introduction to the series and our first article, which is by Fuller Torrey. Neither Dr Frances nor Dr Torrey need much introduction, since they are both well-known advocates for system change.

As I said in last month’s column, I know few of us have the time or inclination to do much advocacy. But, I hope this new series of articles will provide a bit more impetus for us to get out there and educate the public and political and corporate decision makers that change has been a long time coming, and that they must act so we can say that time has come today.

I hope all of you have a fulfilling holiday season and a new year of peace, health, satisfaction, and productivity. And we’d love to hear your top 10 hits and misses for 2014 via our Web site: psychiatrictimes.com.