Health Care Thoughts – Public Policy Dilemma
Tom aka Rusty Rustbelt
HEALTH CARE – PUBLIC POLICY DILEMMA
Fifty years ago much mental illness treatment was done in-patient in state run facilities, and many of them were hellholes (One Flew Over the Cuckoos Nest was probably too positive compared to what I saw early in my career).
The de-institutional movement (starting in the late 60s) caused a build up of community based services, and in combination with better therapies has made a much better (although not perfect) system. In many areas the mental illness and substance abuse facilities are run through common governance, some areas not so.
But there are still people who need in-patient services, especially those who also have chronic physical health problems, and there are too few beds and too few payment paths to accommodate those patients.
So what to do?
Some are being dumped into geriatric nursing homes, and not surprisingly the results range from not very good to disastrous. Exact numbers are hard to come by, because the reporting mechanisms do not always separate those admissions. Generally we hear about these cases after something goes terribly wrong and hits the media.
Nursing homes are getting better equipped to deal with geri-psych issues, but younger and often agitated patients really do not fit. A few nursing homes have set up special units or dedicated the entire building to mental illness patients, but not many that I can find.
Nursing home regulatory protocols actually hinder aggressive psych treatments, as regulators and consumers are concerned about “chemical restraints,” the notion that nurses drug the residents into submission and then sit around doing their nails and reading magazines (no psych drugs can be administered without a physician’s order and a thorough care planning process).
So far no one has developed a really good response to this problem, either clicical or financial. The health care reform bill has not directly addressed this issue, although it creates an opening for the discussion.
(For anyone interested in some good reporting go to the Chicago Tribune website and put “nursing homes mental illness” in the search block. The Trib also does a lot of good work on nursing home problems in Illinois. A Google search will yield plenty of information. Also this MSNBC story http://www.msnbc.msn.com/id/29781318)
Tom aka Rusty Rustbelt
Thank Ronald Reagan for creating this disaster, many of the so-called homeless actully lived in those state hospitals, because they are actually, mentally ill.
Thomaso, read this again: “The de-institutional movement (starting in the late 60s)…” That was long before RR’s presidency. BTW, most of the facilities are mostly state run and funded with some Fed. funding help.
It was Reagan who put a large numbers of psych patients on the streets. Residences closed, treatments unfunded, etc.
In 1987 a pharmicist coming out of a bank on Main St (USA) two blocks from the hospital he worked at was beaten to death on the street during his lunch break.
The assailant was on the loose, with either no or poorly supervised treatment directly because of Reagan. The ex Mrs. ilsm was a nurse in the community at the time. The assailant was one of a number of uncovered patients hanging around town.
Deinstitutionalization prior to Reagan was group homes and extensive outpaient care. That was too expensive when Reagan was rebuilding the military industrial complex for the war profiteers.
Who tallies the cost of all the militarists’ damage?
well, the first thing i thought
reading Tom’s piece, is that the lesson of de-institutionalization was that crazy people did a better job taking care of themselves than sane people did taking care of them.
then ilsm spoiled my laissez faire reverie.
In MA it was a brutal transition. Parents and advocates for kids and adults with developmental delay symptoms wanted some of the institutions closed, but the transition to more community based programs was full of trial and error as the need outpaced the ability of providers.
The state’s department went from a very minor one to a department with millions of dollars to spend.
I spent a fair amount of time in 2008-2009 visiting in a nursing home in Vt.
The majority of the population seemed to be Alzheimers or Senile Dementia. A small number, my reason to be there, were folks too sick for assisted living, on hospice and/or not needing to be in hospital.
I saw Cookoo’s Nest, I am not sure the nursing home is any better or worse.
Reagan did not get rid of involuntary commitment, which is the number one problem in getting many mentally ill treated. I know as I have a scizophrenic in-law. Just try getting a mentally ill person to stay on their meds or in a safe place.
You need to read some history of teh issue – the Governmnet royally screwed this one up – not specifiacally Reagan, and much of teh problems pre-dated Reagan.
http://www.mentalhelp.net/poc/view_doc.php?type=doc&id=368
Wrong, see my tale below.
It seems to me that this problem startred in the sixty’s early seventy’s in California. Reagan was the Governor at some point during that time. Not sure that he was the instigator there, but, as with all Republican governmrnt leaders, they want to cut/kill anything social. I have always wondered what drives them to hate helping the less than whole [read the sick, the blind, the mental impaired] to save a few bucks, while they waste vast sums on outmoded upgrades for government with the excuse being; “it’s for security”. It seems that quite a bit of the so called security has to deal with contractors bottom line, instead of anything else. Don’t misconstrue this as a stab at just the Republicons, for the Democrates are guilty of their own wasteful spending/cutting too.
No, you are wrong read the link. It is a long history of governmnet botching care for the seriously, mentally ill.
I understand the feeling mcwop, as I used to deal in these issues, but involuntary committment is a serious intervention legally, and given the resources allowed for government intervention, much less private care, we don’t offer a lot to mental health to cope. Mental health is a poor second cousin both in private insurances and health cares and gov. I wouldn’t reserve condemnation for just the government for things the private sector avoided even looking at for a long time.
I see the mental health issue as a key government function, specifically because they make the laws that govern much of what can be done. Further, the seriously mentally ill are people truly in need of help. Many cannot hold a job, or function. I am not saying involuntary commitment is the answer, but the notion that the mentally ill wandering the streets are some sort of “freedom” is insane in and of itself. I have no problem with the government using tax money to build nice facilities for the treatment of the mentally ill – rather that than building bombs.
Most families do not have the means or expertise to care for a seriously mentally ill person. We could not take my mother-in-law in, because she was a danger. After more than a decade my wife got her into a group home, finally got Social Security to determine she was disabled. She was homeless at times, went missing etc… but there was no legal recourse to get her treatment, she would have to stab someone first. We got lucky, but many wandering the streets of Baltimore are not so lucky. But my wife worries every day when her mom decides to just walk out the door of the group home.
The government provides more support to mom’s that pump out babies in Baltimore, than they do the mentally ill who have little choice in the matter. I mean this seems to be the core function of government, and if they cannot get this one right, then I am not sure what to think.
On a lighter note, it used to be the law in Connecticut that a person could be committed for 90 days observation on the signature of a single M. D. There was an incident where one of two feuding M. D.’s committed the other one. 😉
mcwop
i have to agree with you up to a point. but also with rdan. ilsm, tom, and…
you would need to carefully imagine what you think the answer is. and then talk patiently with others who have other ideas. it is no light thing to confine someone against their will.
in the first place it is a terrible crime against them, justifiable only in extreme cases of protecting them or protecting others. in the second place, places of confinement become hell holes. in the third place the people doing the confining are not always obviously sane themselves, or competent.
the “poor cousin” status of mental health is because of the expense, and the poor prognosis.
best reason for going to med school yet.
http://www.bmhsi.org/bmhsdscr.html History of services in Baltimore. It is usually considered a local problem, or a school problem. Local resources are not adequate. But believe me when I say there are no votes to get when such services are suggested. And no glory. And no prestige working in the field.
Funding for many services is local with support from state funds. It is a long term and expensive process.
http://www.texmed.org/Template.aspx?id=6491
In 2007, legislators invested $82 million to redesign the state’s mental health crisis system. Even though the new funds only represent about 5 percent of local mental health authorities’ (LMHAs’) budgets, it was a much-needed boost. LMHAs were directed to use the funds to support 24/7 crisis hotlines and mobile crisis outreach teams to respond to crises at schools, homes, or other settings.
Other services that LMHAs may develop include expanded outpatient services, extended observation services (up to 48 hours), 14-day crisis stabilization units, and coverage of costs incurred by local law enforcement transporting patients with behavioral health needs.
Congress passed legislation in 2008 that requires group health plans with 51 or more employees to treat mental health disorders the same as other medical conditions. Mental health parity in health coverage is an important step.
Inadequate state funding puts the burden on local resources, and leads to increased rates of incarceration and higher use of public hospital emergency rooms, homeless shelters, and the foster care system.
Parity for mental health services as mandated by law is a joke, but it helps. Still, a heart surgeon or plastic surgeon have a lot more prestige in the grand scheme.
At the beginning of the war in Iraq, mental health care for National Guard in MA had no mechanism even for funding…PTSD…a well documented set of symptoms. We had projects for special training for police on domestic violence from a decade earler which helped with attitudes, but it took a network of volunteers to help families. Of course it has remained invisible to most. And these were the good guys, not the crazies.
in the first place it is a terrible crime against them,
Isn’t letting them be homeless and helpless also a terrible crime against them? Also there is no reason why these hospitals/homes have to be hell holes. Believe me, the streets of Baltimore make a hell hole look good.
Hell holes are created from lack of resources. When was the last time staff from such places were rewarded with a trip to the Bahamas for doing a good job…you know, company spirit stuff. Or a line staff that made more than $30,000/year (2 jobs needed?).
At Seeking Alpha a commenter claimed that working hard 60 plus hours a week at a productive business and giving thousands of dollars to charity (local charities) justified his view point for Republican ideas on tax cuts…we opt for the priorities we value.
Often we don’t put two and two together. I am sorry for your troubles mcwop, but the funding is local, and has no constituency even locally. And working in the field limits your income severely, even if you work extra hard.
You can look at it in a variety of ways, but welcome to the world of advocacy for particular causes. It is arduous and gut wrenching and draining when you care.
Oneof the concerns about parity (from health insurers) is that for profit psych companies will game the system a nd suck it dry. I tend to concur with that opinion.
Anyone with 30 days of inpatient insurance seems to get a doctors order for 30 days of inpatient service.
At least the nh staff has some resources and training to deal with geri-psych, a 47 year old schizophrenic with substance abuse problems really doesn’t fit so well.
Reagan has been blamed for everything but bad breath in dogs. Geez.
Rdan
chin up. i don’t think Peter and Paul had a lot of prestige in the grand scheme. the workers in the vineyard never do. but their’s is the important work.
ah, rusty
you have identified the whole problem with insurance.
As I approach my own senility phase I seem to remember that in the 70s the feds put in a lot of seed money and block grant money with the intention that the states would eventually take more responsibility.
One detour was created by a new menace, wide spread drug abuse which sucked up a lot of funds and created new mental illness problems.
The good news is that through all of this there exist some decent community services. The bad news is the system does not manage 100% of cases (or even 100% of the patients who want help).
Any one got any solutions?
mcwop
can you imagine putting all of those peoples into an “institution.” believe me, you haven’t seen a hell hole. much less considered the problem of who gets to be involuntarily committed.
i talk to our local homeless from time to time. they are indeed crazy. but most of the time (most) they can take care of themselves. they’d be better able with just a bit of support instead of the periodic police clean up.
being a little crazy myself, i can imagine sleeping in the woods and being perfectly happy. can’t imagine being locked in a building with other crazy people and mad doctors.
CoRev
inclined to agree with you here. Reagan was not the source of all evil in this world. But he was a sign of the times.
Well, that is a catch twenty two if ever there is one. But for profits tend to suck as hard as they can in any field of endeavor it seems.
If meds are involved, which is measureable externally, it can take two weeks to get someone off and then begin something new. I can tell you stories of suicidal patients having at most 3 day observations and discharge.
It is a bewildering set of criterion, and I live in an area that has some of the best at it.
To me. it is a misallocation of resources. Instead of 40 cents of every discretionary federal dollar being spent on the military, that could be spent on quality of life issues. The position I have been advocating is that the Federal government needs to cut its tax take, so States and localities can increase theirs and spend on their needs, which can vary greatly by state.
I think there is a constituency for it here in Baltimore, but the city cannot increase its tax take any more as it is crowded out by Federal taxes. Local politics is also more responsive than federa.
save_the_rustbelt: “Anyone with 30 days of inpatient insurance seems to get a doctors order for 30 days of inpatient service.”
Oh, you bet. But maybe they should be getting 150 days of outpatient insurance instead.
Rdan: “Hell holes are created from lack of resources.”
Not always. Remember that the first nursing home in the U. S. was run by a serial killer. Payment in advance!
Fair enough.
stop electing them to Congress?
hey, i know where bad breath in dogs comes from.
reagan is not off the hook.
Hi McWop:
Not trying to be argumentative. Much depends upon the state you live in now. Staes like Wisconsin hve good benefits for the mentally ill and elderly. Other states rely on the prisons to house the mentally ill and those with disorders. You can be declared mentally ill but guilty which is the same as guilty and get the same sentence even though you do not know what you did.
Norman, “It seems to me that this problem started in the sixty’s early seventy’s in California”
No Norman, the problem is eons old. What to do about the mentally ill is still a question that has no clear answer, as this discussion clearly indicates. The one major stumbling block is the intractability of mental illness itself. And it is not the behavior of the patient that I refer to, but the discovery of a real “cure.” I say that in quotes because I don’t see any significant improvement regarding the improvement in the treatment of ideational disturbance. There are drug treatments for behavioral manifestations of the mental disturbance. That’s not the same as finding the means by which the ideational component is better understood and a control mechanism is found.
That’s the intractability I refer to. No real cure to date for most forms of mental illness. Some psycho-pharmacological approaches which seem to help control and modify behavior, but do not clearly improve the ideational disturbance that pushes the individual into all manner of difficult behavioral episodes. And it has been so for the length of man’s recognition that such afflicted were not simply good choices for tribal shaman. The period before the ’70s, if that’s when the pits were closed up, did little to resolve mental health problems. Those struck low were simply warehoused if their families could not, or did not have the resources, to cope with the behavioral manifestations of the individual’s madness. Psycho-pharmacology provided, and still does, a less expensive and less restrictive environment for the individual caught in the web, but the web still restricts that person’s life. We don’t really know what the ideational change is during the phase of treatment. The patient seems more stable, or is that patient simply more docile? Pre-frontal lobotomy also “changed” the patients’ behaviors.
Psycho-pharmacology is less intrusive. Or so it seems to be.
Medicine doesn’t have an answer and the community can rarely cope with the cost of wide spread quality treatment, if there is such a thing. What we do know is that the cost is great and the results are mediocre. A bit of a social dilemma.
Bedlam
it occurs to me in case anyone cares
that insurance should be reserved for the real catastrophes that no one would”voluntarily” let happen.
it should not be used to pay for petty expenses. thus, if your mercedes gets dinged and you think it is worth 3000 dollars to make it pretty again, you pay it, you don’t have insurance to pay it. because as long as people have insurance to cover petty expenses, they will find a way to use it, driving up not only the cost of insurance, but the cost of “repairs.”
adapt this to medical expenses at your pleasure.
the only reasonable way to pay for “routine” examinations, for example, would be for the insurance companies to decide that by paying their customers to get the exam they would reduce their long term costs. and that means something that looks like a positive actual cash rebate, not just a “we pay it if you take it” part of the basic insurance package.
what does this have to do with mental health care? i dunno. not much maybe. but i suspect it might.
it occurs to me that i am taking care of eight mental paitients right now.
they have eaten their beds, their water dish, the walls and floor, and spend a lot of time
snapping and growling at each other.
what keeps it from becoming a hell hole is that i have the time and moral energy to keep more or less on top of things.
time would translate as money if we were talking about people and society’s response. moral energy would depend entirely on electing and empowering someone who was able to give the problem energetic, honest attention.
that has never been a reliable quality among elected people or those they hire to manage specific problems, probably it’s remarkable that we do as well as we do.
still, i wouldn’t be too eager to involuntarily commit “insane” persons either because some of them hurt other people, or because someone we love might hurt themselves. i think there are always going to be tragedies in iife and we need to be careful that we don’t create more and bigger tragedies by using a bigger hammer than the situation warrants.