The Edge

Most children look forward to the school days when they really never enter the classroom at all: field trips. Of course, field trips were always explained to parents on permission slips as “educational experiences,” but try telling that to an eight year old.

Field trips have the same effect as an adult; I spent Thursday’s work day at a medical interoperability conference. Sounds vague and uninteresting? Let’s try an example.

Your child is very sick. So sick they have to go to the hospital. You go to visit them in the hospital and the room is overflowing with medical devices, most of which are hooked up to your child, some of which are powering each other. Through the long wires, connected to the cold, boxy structures, which beep every half minute, you see your child, lying in their hospital bed, asleep. All you want is to hug them but you can’t. Will you accidentally bump one of these monitors and inadvertently hurt your child?

Medical interoperability: making devices talk to each other. What if you had one device that could monitor 20 things, because it could send signals remotely? What if because of this you could hug your child?

You can’t though because what this conference was about was why medical interoperability isn’t a reality. It doesn’t exist. Machines don’t talk to each other and state of the art technology is the term used by hospital executives to describe devices that can send results to a printer. How did medicine become the least innovative sector of our economy?

There’s no business interest in making them talk. It’s like when Apple and Microsoft created their computers, with separate operating systems, that didn’t talk to each other. They don’t want to talk to each other because then you won’t buy more of their products. They want you to be reliant on them. It’s the same thing with medical devices, including electronic health records, which are quickly becoming the future of medicine because of payment reforms. Essentially–the government promotes the use of electronic systems because that’s how the government gets its performance measurement data so that they can pay the doctors and hospitals for giving quality care. Bye, bye fee-for-service, hello value-based payments.

Only there isn’t quality care associated with these systems, most doctors, hospitals and patients say, because they’re too worried about trying to make these systems work. It’s time consuming and expensive. Doctors should be focused on the patient, not on a screen.

Enter Malcolm Gladwell, highlight of the field trip. What is Malcolm Gladwell going to tell us about medical interoperability, you ask? Well he’s got three stories, actually, the most important one, I think, being the story about the edge.

If you’re not at the edge, the breaking point, the do-or-die moment… then you’re not going to act.

When do we get to the breaking point?

It’s not a question that the conference answered. Maybe that’s because we don’t know. We don’t know what it takes to spur change. And we can say that about a lot of problems the United States is facing. We think we’re at the point of urgency, when something must get done but we don’t do it. Gladwell suggested it’s a framing issue. But we had 20 children die in Sandy Hook Elementary and we didn’t do anything about guns or mental health. Framing issue?

It might take awhile, but electronic health records will be easy to use, someday. Luckily for those, it’s a technological development that is just going to have to happen. So in some ways, it’s nice to know that what seems annoying now will improve over time, because there’s a consumer demand for it, albeit not a strong one. On the other hand, not every issue is so easily remedied. It seems so frustrating that we are able to identify problems and not agree on solutions. But it’s worth wondering if what Gladwell spoke of–being on the edge–is exactly where America is now. This divisiveness in our country is unsustainable. Even Glenn Beck apologized for contributing to it. And you have to wonder what it will take–who it will take–to get us to the other side.

Obamacare and Mental Health

A version of this article appeared in National Journal Daily on Wednesday, October 15, 2013.

In the last year, the shootings at Aurora, Newtown, and the Navy Yard have fueled a conversation about what the country should do to keep people who suffer from mental illnesses from becoming a danger to society.

But when unarmed Miriam Carey was killed after leading police on a car chase to the U.S. Capitol—which ended with officers firing multiple shots at her vehicle—it highlighted the fact that people battling mental illness are more than just the perpetrators of tragic shootings.

Two U.S. Capitol police officers were put on modified duty following the death of Miriam Carey. Carey -- who struggled with depression -- was shot in her vehicle after leading police on a chase to the Capitol complex.
Two U.S. Capitol police officers were put on modified duty following the death of Miriam Carey. Carey — who struggled with depression — was shot in her vehicle after leading police on a chase to the Capitol complex.

A discussion about limiting access to guns for people with mental illnesses wouldn’t have changed Carey’s fate. But policy action to improve patients’ access to insurance and reduce the cost of treatment options could have filled a void for Carey and the other Americans whose inner struggles ended in moments of national pain.

To be sure, not all mentally ill patients are violent. Dr. Eliot Sorel, a clinical professor of psychiatry and behavioral sciences at the George Washington School of Medicine and Health Sciences, said that while the news stories illustrate a problem in health care, they also create a stigma around mental illness. He said that not all people who commit violent acts are mentally ill, and those of them who are are typically not seeking medical help.

“The severely mentally ill who are not in treatment are the ones who are potentially violent, and we need to attend to this,” Sorel said.

Increased access to mental health services is one component of the Affordable Care Act, and insurance coverage in the health law’s exchanges begins Jan. 1 for those who sign up by Dec. 15. The full implementation of the ACA, according to a February 2013 Health and Human Services report, will provide first-time access to mental health services for 32.1 million Americans.

The new health law requires all insurance plans in the exchange and in the individual and small group markets to treat mental health services equally with other forms of care in terms of copays and deductibles. Traditionally, insurance companies did not cover—or required higher out-of-pocket costs for—mental health services. Sen. Debbie Stabenow, D-Mich., proposed the parity requirement as an amendment, which was passed and added to the ACA, reflecting the existing requirement for mental health care parity in large employer-sponsored plans.

“After each one of these tragedies, everyone talks about improving mental health services in America,” said Stabenow, who is working now on legislation to heighten the quality of care for uninsured patients seeking mental health treatment in community centers. “It’s time to finally take action to do that.”

Lack of insurance and high costs of care are the biggest reasons mental health patients don’t seek treatment, according to a study released in this month’s Health Affairs, a top health policy journal.

“People with mental illnesses are more likely to have lower incomes,” said Kathleen Rowan, a doctoral student at the University of Minnesota and the primary author of the study. “That’s because mental illness might be limiting in terms of the work they are able to do or the hours they are able to work. And so many people face cost barriers in terms of access to care.”

The law will open the doors to affordable care for many of these individuals, Rowan said, through the subsidies on the exchange and the expansion of Medicaid.

Stabenow’s communications director, Cullen Schwarz, said that had the Navy Yard shooter had access to treatment, there could have been a different outcome. People who go without treatment after experiencing their first psychotic episode are 15 times more likely to commit acts of violence than those who do receive treatment, he said, citing a study in Schizophrenia Bulletin, a psychiatric journal.

“It’s not that we’ll always stop these tragedies from happening,” Schwarz said, “but we can certainly strengthen mental health services and reduce the number.”

The next obstacle, Rowan said, will be whether the scope of services and the number of doctors are able to meet the increased demand for mental health care.

For lawmakers, one solution might be adding incentives for physicians, nurses, psychiatrists, and other health care providers to adopt an integrated, team-based approach. Sorel said collaborative care restructures the system in a way that meets the total needs of mental health patients and creates communication between providers who could potentially stop the patients from taking violent action.

“You know what our biggest provider of mental health services is?” Sorel said. “U.S. jails and prisons. That’s the result of us not attending to this need.”