by J Nelson
For decades now, psychological scientists have demonstrated that savings from 30 to 60
percent in medical costs and much better health outcomes are possible if we give up the
biomedical model and embrace the psychological-social-biological framework instead, called
integrated care. But can Louisiana make this change? In this article we review where we are
and where we’re going, and some of the barriers to change that seem to persist.
If the famous axiom is right, and we have to hit bottom to get better, Louisiana should be due
for improvements in its health and healthcare system. Last year U.S. News & World Report
ranked 50th overall with a 45th in healthcare. The rank included a 43rd place in mortality, a
46th in infant mortality, a 50th in obesity, and a 43rd rank in smoking. At the same time,
Louisiana’s costs are high–the Report placing the state at 45th in health care affordability.
This pattern of poor health outcomes and high costs reflects the country as a whole. The
United States ranks 50th out of 55 industrialized countries in a measure of life expectancy
and medical care spending, according to Bloomberg, who concluded the U.S. is the “least efficient” health-care system in the world.
Yet, healthcare is the largest industry in the country, accounting for almost $3.5 trillion in sales in 2016,according to the National Health Expenditure Data from CMS. More recently, the industry is now also the nation’s largest employer.
The sheer size and complexity of the healthcare industry would suggest that innovations would be challenging, but change may be even more unlikely because of the political power yielded by the industry. Last year the pharmaceutical industry, Blue Cross/Blue Shield, the American Hospital Association, and the American Medical Association were the 4th, 5th, 6th, and 7th highest contributors to Congress, and the year before that pharmaceuticals and insurance was 1st and 2nd.
Given this, it is surprising that the American Psychological Association (APA) recently managed to grab a little territory for psychological assessment, now finally considered as a “thinking” valued activity, in the newest Rules. A feat which required behind closed-door negotiations.
Healthcare is a Closed System
The medical-pharmaceutical-hospital-insurance industrial complex has a firm hold on the prices and services in this country, through the “CPT Codes” and the “Relative Value Scale Update Committee” or RUC. These groups decide what services are allowed and how much they are reimbursed.
Three hundred “Advisors and Experts,” primarily from the American Medical Association’s House of Delegates, representing 109 medical specialties, attempt to influence an “Editorial Panel,” composed of representatives from medical societies, insurance companies and the government.
This panel conducts closed meetings and decides on what healthcare services are paid for, and which are not, by way of the complex set of codes known as CPT or “Current Procedural Terminology.” CPT is owned by the Center for Medicare and Medicaid Services (CMS), leased to the American Medical Association (AMA), who then copyrights it and strictly controls the development of new codes. The RUC assigns the value to the service, and somehow this is not considered price-fixing or restraint of trade.
The system includes the FDA, which receives 40 percent of its funding from the pharmaceutical companies, Dr. Irving Kirsch, Associate Director of the Program for Placebo Studies at Harvard Medical School, has explained. Kirsch has also laid out evidence that drug companies and the FDA skew research to approve drugs that have little actual value.
At a 2015 meeting of the Louisiana Psychological Association, Dr. Tony Puente, now a past-president of APA, was one of the two outsiders allowed to participate in the CPT process. “Essentially,” he said, “the CPT tries to divvy it up in a way that is theoretically and empirically, and diplomatically and politically, correct.” Participants must sign a strict AMA confidentiality
agreement and declare, “I will not disclose, distribute or publish confidential Information to any party in any manner whatsoever.”
To decide on reimbursement, 28 voting members on RUC, representing medicine specialties such as anesthesiology, cardiology, neurology, neurosurgery, obstetrics, oncology, psychiatry, and so on, meet and decide how much each service is worth, and how much is to be paid.
An underrepresentation of primary care in this system and an undervaluing of their contribution, has lead to high-cost specialists and a shortage of primary care physicians, according to the Robert Graham Center for Policy Studies in Family Medicine and Primary Care. This has been shown to negatively impact outcomes. In a special issue of the American Psychologist on Primary Care and Psychology, Dr. Susan McDaniel and primary care leader Dr. Frank deGruy reviewed evidence that for each primary care physician added to a social system, “all-cause mortality decreases by 5.3 percent.” Conversely, for every specialist added the mortality rate goes up 2 percent.
Healthcare is a Misnomer
“Health is a misnomer, because most activity involves illness. Health care and medical care are not synonymous,” said Hamilton Moses and co-authors in, “The Anatomy of Health Care in the United States,” in a 2013 article of the Journal of the American Medical Association (JAMA).
“Prevention requires tools that are often unfamiliar because educational, behavioral, and social interventions, not usually considered to be part of medicine, may be most effective for many diseases,” Moses wrote.
While medical costs are driven by chronic disease, it is not due to an aging population, even though age is often cited as the cause. The JAMA authors show that about 80 percent of the total health care cost is accounted for by those under 65, and relate to psychological, social and behavioral elements. The CDC estimates that lifestyle factors account for 80 percent of heart disease and stroke, 80 percent of type 2 diabetes, and 40 percent of cancer.
“Behavioral intervention is the foundation for lifestyle medicine,” writes Dr. John Caccavale, author of Medical Psychology Practice and Policy Perspectives. “Of the top four classes of medical problems in America – metabolic disorders, respiratory disease, cardiovascular disease, and mental disorders – physicians will have great difficulty demonstrating that they are improving patient health by utilizing medications as a first-line treatment for these classes of disorders,” writes Caccavale.
For decades now, psychological scientists have known that behavior is the key to costs. In an interview with primary care psychologist, Dr. Michele Larzelere, she explained that psychological scientists have agreed that those using an integrated care model can expect a 30 to 60 percent reduction in medical use costs.
And, unlike medical care which carries a large risk, behavioral treatments have few side effects. The author of Unaccountable: What Hospitals Won’t Tell You and How Transparency Can Revolutionize Health Care, Martin Makary, MD, found that medical error, unrelated to the illness or injury, is the third cause of death nationwide, following only heart disease and cancer deaths.
“It boils down to people dying from the care that they receive rather than the disease for which they are seeking care,” Makary said in a report by The Washington Post. Health is woven into a complex set of social and psychological behaviors, not a single cause. “Socioeconomic status is one of the most powerful predictors of all cause mortality,” says Dr. Chris Leonhard, health psychologist and Professor at the Chicago Professional School at Xavier.
“New Orleans is a startling example of this,” Leonhard said. “Life expectancy at birth in the Tremé where the average household income in 2010 was about $26,000 is 55 years, while in Lakeview, the average 2010 household income $75,000, and life expectancy at birth is 80 years.”
Outdated Treatment Models: The Opioid Crisis Example
A dramatic example of flawed decisions in the medical/pharma industrial complex is the opioid crisis. Twenty years after a marketing blitz aimed at convincing physicians that opioids were safe and effective, the over-prescribing of this heroine-type drug has catapulted overdose deaths to a rate higher than auto fatalities, HIV or gun deaths.
Louisiana is in the middle of the crisis, with some of the highest opioid prescribing rates in the nation and an escalating death rate from overdose. Last year in a Louisiana House Health and
Welfare Committee hearing, Representative Helena Moreno told members that there are “… more opioids prescribed in Louisiana than are people in this state.”
Despite the flood of legal opioids into the society, the CDC reported no change in pain that would meaningfully drive the prescribing: “…there had not been an overall change in the amount of pain that Americans reported.” The CDC found that there was no long-term benefit for opioids compared to no opioids. However, they did find ample evidence for harm.
In contrast, the CDC did find that psychological and physical treatments for pain were beneficial (“CDC Guideline for Prescribing Opioids for Chronic Pain”). This despite the fact that these non-medical approaches are rarely integrated into treatment programs.
“It is now widely accepted that pain is a biopsychosocial phenomenon,” clinical health psychologist and Past-President of the Southern Pain Society, Dr. Geralyn Datz, told the Times. “For many years the biomedical model of treatment has prevailed as a way to treat pain patients,” Datz said. “This model is based on some very early research about acute pain,” she said. Things are very different now. “We know that chronic pain is a complex and dynamic process, and it involves a person’s thoughts, beliefs, experiences and these all can influence pain for better or worse. In addition, conditions such as depression and anxiety can arise from the presence of pain, and these also can worsen pain through interactions of the brain with the body.”
The intentions to blend psychological factors with traditional healthcare seem sincere in Louisiana. In the Medicaid Annual Report for 2017, the Medicaid Director Jen Steele wrote of her mission to improve quality, patient experience, outcomes and lower costs. And, some progress with Patient Centered Medical Homes has come about.
However, making significant changes may be challenging. Using data from both Medicare and Medicaid use, Louisiana’s costs are above expected in a number of areas. The Kaiser Family Foundation looked at data from 2014 and Medicare spending per enrollee, and found that Louisiana ranked 10th in Medicare spending compared to other states, with New Jersey, Florida, New York, Maryland and Connecticut at the top five.
Data from Dartmouth Atlas of Health Care found that Louisiana has a high average number of inpatient days per beneficiary. In a detailed breakdown from 2012, Dartmouth found that Louisiana had the highest number of inpatient days per person compared to all other states.
Louisiana averaged 6.0 days per beneficiary while the average across the nation was 4.6 days.
In a group for comparison of multiple chronic conditions Louisiana fell above the 90th percentile again with an average of 20.8 days, while the average was 17 days. For dementia the average number of inpatient days was 30.5, and national average was 22.5.
The Alexandria, Monroe and Shreveport regions are some of the highest areas of hospital usage, based on Medicare data collected by Dartmouth.
Dartmouth found that in 2015, the national average of hospital usage was 254 per 1,000 Medicare enrollees. Louisiana averaged 279.8, and some regions were the highest in the country Alexandria was 335.4, Monroe 325.0, Slidell 320.5, and Shreveport was 294.
Dartmouth researchers note that, “Regional variation in hospital and physician capacity reveals the irrational distribution of valuable and expensive health care resources. Capacity strongly influences both the quantity and per capita cost of care provided to patients.”
In the Louisiana Medicaid 2017 Annual Report, the top 10 provider types, ranked by payment, were first, hospitals, at $1.3 billion, and second, pharmacy, at $726 million. Dentists were third at $162 million, then mental health rehabilitation at $140 million, nurse practitioners at $115 million, and behavioral health rehabilitation agencies at $114 million. Distinct psychiatric hospitals were next at $76 million and freestanding mental health hospitals at $69.7 million.
In comparison, other providers, which include audiology, chiropractic, personal care attendant, physical and occupational therapy, psychology, social work and other services not covered otherwise, totaled $917,000.
The need may not be being met, even in this picture. In a 2018-2019 Combined Behavioral
Health Block Grant Plan, published in late 2017, the state noted that the number of persons being served was 3.29% of the estimated prevalence. The estimated number of children/youth with serious emotional disorders was said to be 38,803 and only 1,370 had been served. The prevalence estimate for adults with serious mental illness was 192,019 and only 7,590 had been served.
In the grant report, the state confirmed that it was building its workforce and ability to function in an integrated care environment. The state has indicated progress in developing integrated care in some ways, looking for its managed care companies to advance the plans.
However, in a list of “Specialized Behavioral Health Services CPT Code” and reimbursements, effective July 2018, the fee structures provide little in the way of reimbursement for health and behavior, or any clear mechanism for integrated services. The “health and behavior” services pay between $12 and $15 and are only listed for a psychiatrist, nurse/physician’s assistant, medical psychologist, and a psychologist. There are none listed for clinical social workers or counselors.
Some codes and fees are listed for psychotherapy. Individual psychotherapy is reimbursed at 69.76 for psychiatrists for 45 minutes, $55.81 for nurse practitioners and physician assistants,
$55.81 for psychologists, and $48.83 for social workers, counselors, and marriage and family
therapists. But this may not translate to integrated care. And group therapy, a valuable therapy mode for many issues, is paid at only $23.23 to $18.58 and there is no reimbursement for the social worker or counselor listed on the current fee schedule.
These arrangements may explain why there are few providers who chose to participate. Access to care and rates have been a problem nationally, with nearly half of all providers not offering Services to Medicaid patients. Nationwide, Medicaid fees are about 72 percent of Medicare, which is about 80 percent of private pay. Only about 130 psychologists were listed as providers on the 2014 Medicaid rolls, according to a report at that time.
One Representative’s Efforts
During the Louisiana 2016 Regular Legislative Session Representative Barbara Norton from Shreveport put forth a measure, House Bill 1164, to create a task force to study the delivery of
integrated physical and behavioral health services for Medicaid enrollees who suffer with serious mental illness.
Norton brought together an array of associations and state agencies from across disciplines and from across the state to look at ways to improve the care offered by Medicaid.
She told the Times, “This was an opportunity to pull so many people together, at no cost. I met with many of these people who felt as I did, that this would be a great piece of legislation, that they want to help the state of Louisiana and health, and make a real difference.”
The bill passed committee with a 10 to 0 favorable vote. But then, on the House floor, it failed with 51 nays and 33 yeas. Five of those who had supported it in committee switched their votes on the floor and twenty did not vote. Why? Representative Norton thinks it might have been political. “We still feel the Medicaid belongs to President Obama but it belongs to all of us and we’ve not started to understand the significance of these issues.”
Representative Norton tried again in 2017, this time passing a measure as a Concurrent Resolution, asking again for the study of the issue by a comprehensive task force, HCR 55. The
measure passed easily and task force was formed. However, she said that the task force met only twice. The Representative will be calling another meeting in December in Baton Rouge, she said. “It has not been given a fair shake.”
“My goal is to go back with whomever and find out what we can really do for the people because the problems in this area are so serious,” she said. “We’ve not even started to understand the significance of what this should be about and the more we look––the shootings the mental health issues––the more it’s necessary that we reach out to all the people and look at all the facts that there are, and continue to work. Because we’re talking about peoples lives.”
“I understand that sometimes people don’t know the type of leadership it takes but if people want to be on the committee, and care to discuss these real issues, then it’s not the type of thing where a person can call in or send information. We need to discuss ideas and plans,” Norton said.
“I do believe that at the end of the day, with the help of leadership, we may turn some thinking around, and clearly understand why it is so important to look at all these things. I promise you I’m going to work with this until we see some differences, and people see some hope.”