Featuring Dr. Stephen Kemble, a psychiatrist and former president of the Hawaii Medical Association, and host Brenda Gazzar discussing the burdens of Medicaid Managed Care on mental health patients and doctors alike. This is part one of a two-part series for Mental Health Awareness Month.
Mental Health & Medicaid’s Managed Care Mess
—– TRANSCRIPT —–
Welcome to Code WACK!, your podcast on America’s broken healthcare system and how Medicare for All could help. I’m your host, Brenda Gazzar.
How does America’s healthcare system affect mental health patients and their doctors? Are patients getting better or worse treatment now that private health insurance companies are managing Medicaid? To find out, we spoke to Dr. Stephen Kemble for Mental Health Awareness Month. He recently retired from his private psychiatry practice and practices part-time at a hospital-based primary clinic in Honolulu. The longtime healthcare reform advocate is also past president of the Hawaii Psychiatric Medical Association and the Hawaii Medical Association.
(5-minute stinger music)
Welcome to Code WACK!, Dr. Kemble.
Kemble: Thank you.
Q: I’m curious what you’ve noticed in terms of how the field has changed over the years?
Kemble: I trained in Cambridge Hospital in the Harvard network in community psychiatry in the 70s. And I moved back to Hawaii where I grew up in 1985 and at that time, I was in mostly private practice, and our Medicaid program here was served largely in the private sector. In other words, all the psychiatrists in town took at least some Medicaid. Most started their practices building on Medicaid and then kept maybe 25-35% Medicaid on throughout their careers.
The state introduced Medicaid Managed Care in 1994 and then for the aged, blind, disabled population with all the seriously mentally ill in 2009. And that has effectively driven the psychiatrists out of Medicaid so there’s hardly any that take Medicaid any more. And the only places Medicaid patients can get care is in Federally Qualified Health Centers and in the hospital clinic where I work that is subsidized to serve the Medicaid population, but the private (psychiatry) sector has gotten out of Medicaid because of Managed Care.
Q: And what kind of impact do you think that has had on patients?
Kemble: Well, it’s really hampered access to care. There isn’t enough available care in the Federally Qualified Health Centers. Some of them have hired their own psychiatrists but a lot of them have not or I know one that tries to but they have had high turnover. They keep leaving. And if you’re living in one of the neighboring islands, Maui or the big island, there are no psychiatrists available anymore. Everybody quits. No one is willing to put up with that.
Q: Umm. So how else has America’s healthcare system failed those with mental illness?
Kemble: I think probably the biggest problem is what’s happened as a result of Medicaid Managed Care because it’s not just in Hawaii. In every state, it’s really diminished the number of doctors willing to take Medicaid patients because Medicaid patients, the pay is always lower than other kinds of insurance.
The level of illness and difficulty and complexity is generally higher, but at least here in Hawaii, everyone was willing to deal with that as long as we were able to manage care. When the Managed Care organizations come in and strip away the doctors’ autonomy to manage care and start telling them what they can and can’t prescribe and what they can and can’t do, everybody quits. No one is willing to put up with that.
Q: Tell us how standard industry insurance practices conflict with the unique needs of mental health patients.
Kemble: Well, for example, if I negotiate with a patient who’s got schizophrenia and who is not really sure they agree that they have an illness. They think their voices are coming from the CIA and maybe I’m in cahoots with them and they’re very suspicious and paranoid, but you manage to talk through all that and negotiate (for them) to take a medicine. You try to choose something that you think has the least chance of giving them an unacceptable side effect.
The patient goes to the pharmacy and the pharmacist says, we can’t fill this, you need a prior authorization from the insurance company. So you submit a request for prior authorization and a couple of days later, it’s almost always granted and the patient never comes back to pick up their prescription and the next time you hear about them, they’ve been in the emergency room three times and got hospitalized at far more expense than that medication would have cost. This kind of thing has literally happened to my patients multiple times.
Q: Wow. That’s tragic. How else has our healthcare system failed psychiatrists and other physicians?
Kemble: I think that it’s a combination of low pay and excessive managed care burdens. Psychiatry and psychology too were subject to the most intensive interference from managed care of any specialty. When managed care came into Hawaii in the 90s, we could see a patient once and then you had to get permission to see them for the next six visits. And they started restricting the formularies so there are fewer and fewer drugs that you can prescribe without hassles.
Before managed care, if you prescribed a generic you knew it would go through. Maybe if it was a new expensive medicine, you might need a prior authorization. Now they pre-authorize everything, especially for antipsychotics. Just about everything. And because it’s so difficult to get seriously mentally ill patients to agree to take the medicine, and because they have such a high risk of side effects, it’s really a matter of you try something that you think might work out if they have a problem with it you try to switch to something that doesn’t have that particular problem, and maybe the third or fourth medicine you try that you can actually get them to take an adequate dose. That whole negotiation process is sabotaged by Managed Care.
Q: What is the impact of that on doctors where they’re constantly having to deal with these issues?
Kemble: The impact here in Hawaii is they just say I’m not going to deal with this anymore. I won’t take any more Medicaid patients. They might keep their existing patients, because they’re loyal to the patient, but they will not take any new cases. And after so many years, then patients drop out, psychiatrists quit practice or die or move away and then there’s nothing left. And that’s exactly where we are now, there’s nothing left.
Q: So do patients have any options then?
Kemble: Not really. Well, there is one option. This is something I’ve been involved with for the last few years which is psychiatric consultation to primary care using what’s called the collaborative care model where a couple hours a week of my time and a full-time social worker care manager providing consultation to primary care so if they have a patient with a psychiatric problem, they call us. The social worker contacts their primary care doctor and the patient does a full psychosocial assessment, presents the case to me, and I give recommendations to the primary care doctor directly in their medical record, both medication and non-medication recommendations.
And sometimes it’s primarily psychological interventions. But we make sure the primary care doctor knows exactly what to do with regard to the medicines, what to watch out for and we’re available if they have any questions or problems so it gives them a lot more confidence in dealing with psychiatric medicines and psychiatric problems because they know that they have our backup.
Then we follow the patient as long as needed. If they are getting better and doing well we drop back but they have continuity of care with the primary care doctor and we can always step back in if needed. That model seems to work really well. We are funding it as a grant-based program with myself and the social workers paid with salaries. We charge nothing to the patient or the primary care practice. We’ve got about 75% engagement. The patients follow through and get help from us and our track record on improving depression, anxiety and even managing serious problems like schizophrenia and bipolar disorder and dementia is as good as any program I’ve even seen around the country.
Q: Got it. Are there any drawbacks you can think of for such a model?
Kemble: Well there are some patients who are too complex for the model. It was originally designed for mild to moderate conditions like depression and anxiety but because there’s no psychiatrists available in many of these communities, we’ve basically been willing to do anything we can to support the primary care doctors and we’ll consult with any psychiatric problem.
If it’s something really complex like an unstable bipolar patient who’s doing erratic things, destructive things or someone with history of severe childhood trauma who’s got, you know, multiple psychological problems as a result, that really needs more intensive psychotherapy than we can provide and then we function as a triage service because we’ve gotten to know who is available in the community and can help arrange appropriate referrals when needed. And that also takes a load off the primary care doctor because if it’s something we can’t handle, we can help find somebody who can handle it.
Thank you, Dr. Stephen Kemble!
Find more Code WACK! episodes on ProgressiveVoices.com and on the PV App. You can also subscribe to Code WACK! wherever you find your podcasts. This podcast is powered by HEAL California, uplifting the voices of those fighting for health care reform around the country. I’m Brenda Gazzar.
_________________________________________________________________________________
HEAL California is an independent news and information hub focused on the Medicare for All movement.
With non-partisan news, views, podcasts and videos, we highlight the on-going injustices of our broken healthcare system and amplify the voices of those who are most impacted by it.
Our Podcasts shine a light on the failures of America’s healthcare system, while explaining how Medicare for All could help.
Our Media page offers connections to experts and additional resources including links to legislation and studies.
Keep up with the Medicare for All movement!
Follow us on Facebook, Twitter, and Instagram. Subscribe for email updates.
