February 2014  << Back  

  Can't open the PDF? Click here for help.



A view from the ground

Donald W. Black, MD


I‘ve been thinking about mental health care and the Affordable Care Act (ACA) and want to blow off some steam. I am hoping that over time our patients will experience less stigma, that the ACA will help bring parity to mental illnesses with regard to insurance coverage and that access to psychiatric care will improve.

I do not know where you practice, but I can tell you what I observe from the ground here in Iowa. I have noted that over the past decade psychiatric care has become increasingly fragmented. Emergency departments and psychiatric units have closed, the number of psychiatric beds has been reduced, and that it is harder to arrange placement for patients in group homes or care facilities. In my hospital, the psychiatric beds—a number unchanged since I was a resident—are filled most all the time. Our residents often have to send patients who need acute care across the state or even to another state. It has become nearly impossible to transfer patients to state mental hospitals (there are 4 in Iowa) for longer-term care, in part because the state hospitals have cut back on their number of beds. The result is that we are blocked from getting patients in our hospital and getting them out. Insurers often cut off payment because patients no longer need acute care, yet we are unable to get them placed. (Yes, we know these patients don’t need acute care, but what are we supposed to do with them? Put them on the street?)

Even arranging an outpatient appointment at discharge for our patients is difficult both because community clinics are overbooked—and an appointment for a critically ill patient often is months away—or a psychiatrist in private practice is not taking new patients. And reimbursement continues to stagnate. The good news here is that there is such a shortage of psychiatrists (in Iowa, and nationally) that my residents are assured of having busy post-residency careers. I hope these sad facts will change with the ACA. It couldn’t get much worse.

Among the articles published in this issue of Annals of Clinical Psychiatry, Hayley Getzen, MPH, and colleagues report important new data on barriers that prevent us from using long-acting injectable antipsychotics for our patients. As they document, lack of ancillary support at the practice location, patient preference for oral medication, and limited insurance present barriers to using these mediations. As psychiatrists, we need to make sure our patients have access to long-acting injectable antipsychotics.

Brian L. Odlaug, MPH, and colleagues (including Editorial Board member Jon E. Grant, JD, MD, MPH) show that treatment studies of obsessive-compulsive disorder tend to exclude typical patients, mainly because of comorbid conditions. This leaves us to wonder if the findings from treatment studies have much applicability to “real world” patients. What do these findings tell us about how we conduct research? Are our recommendations to patients wrong?

I hope you have signed up for the Current Psychiatry/AACP CME psychiatry update scheduled for March 27-29, 2014 in Hilton Chicago. (Early birds get a terrific discount!) The program features Henry A. Nasrallah, MD, Jon E. Grant, JD, MD, MPH, Thomas Roth, PhD, Raphael J. Leo, MD, George T. Grossberg, MD, Marlene P. Freeman, MD, Anita H. Clayton, MD, James W. Jefferson, MD, and myself. I hope to see you there.