Juggernaut of Healthcare

The ICD is a crucial part of the sweeping changes as healthcare is being industrialized.

Mental health care will not escape this and so clinicians will have to choose to join the new structures and play by the new rules or do something other than ‘healthcare.’ This paper describes the changes and how they all are working together.

This is really just an opinion piece and not research, guidelines, biography, a call to arms or any of the other typical articles.

Join the Juggernaut. Or Don’t

Edward Zuckerman, Ph.D.

Juggernaut: At the annual festival a huge image of Krishna is dragged through the streets on a heavy chariot. Devotees are said to have formerly thrown themselves under its wheels.                                   Juggernaut in crowd              Juggernaut running over people

The Gods of our Juggernaut and their Histories

1. Big Pharma makes big money. The largest component of the increase healthcare costs over the last few decades has been the enormous increases in drug cost and use. “Me-too” and generic drugs have reduced profits, research on their costly side-effects and low effectiveness has accumulated, and government and professional pushback has limited their “unethical” marketing abilities. While the new psych drug pipeline is empty – they have left psych drugs and moved on to cancer and similar high tech fields – there is still enormous profits being made on what is still being prescribed widely.

2. HIPAA was a government effort originating in the praiseworthy efforts of lawmakers to limit the payers’ denials for “pre-existing conditions” by requiring “portability” (the “P” in HIPAA). To determine the effectiveness of this policy the law required computerizing insurance. That is why the largest, and invisible (to us) part of HIPAA was the Transaction Rule. Over the last decade a gigantic computerized system has been put in place by the” insurers.” They signed on to HIPAA’s Security and Privacy Rules and the hassle of being covered entities because they got the ability to replace all the paper and clerks and back and forth of insuring (verification of benefits, copayments/deductibles/coinsurance, Explanations Of Benefits, etc.) with computerization and save billions (which they take out as profit and outrageous salaries, not use to improve services, access, outcomes, etc. The data on this is very clear).

3. The computerization of health care was necessary and then inevitable. Over the last decade we have seen developments that fit together such as:

– The implementation of 4010 and then the 5010 protocols for transferring data. 5010 is incredibly more capable of moving and organizing more data.

– Electronic Health Records. Theses are medical devices without FDA oversight, implemented without pilot studies or cost/benefits perspectives, and without the absolutely essential function of interoperability – sharing data across providers, etc.

– The ICD-10 with its much finer-grained diagnoses. When combined with revised CPT codes these allow the unbundling of services so that each can be billed for separately. Because more services are delivered and billed there is greater income to hospitals (but not providers) and more cash flow for the payers to take a share of.

4. The Affordable Care Act has permanently replaced health care with health insurance (possible payment for care) guaranteeing payers a 20% profit and decision control of all payments and therefore services (“care”). As with all things political it was a compromise – providing (but not guaranteeing) the opportunity for access to minimal care to almost everyone in exchange for ceding control to corporations. For example, payers  dealt with the costs of removing the limits on “preexisting conditions” or other increased expenses by raising the copayments to unrealistic levels (50% of our usual fees) and the deductibles to multiple thousands of dollars.

5. Psychiatry hopes to stay alive as a medical specialty and not become a just neuroscience. Psychiatry has been shrinking in numbers and quality for many years. Theirs is a harsh situation with a non-unique skill set (psychopharmacology, diagnosing), the abandonment of both historical medical skills and psychotherapy, and the absence of multipliers in their work. While profitable, escaping insurance is not a viable long-term strategy. The recent DSM-5 should be viewed in this light: publishing is more than half of the APA’s income, owning the diagnoses by writing the book that everyone needs, and medicalizing  more problems in living have been good strategies. Having said all this, I must recognize that the neuroscience may yet help psychiatry. See, for example: http://www.frontiersin.org/Journal/10.3389/fpsyt.2013.00178/full

6. Healthcare corporations seek to maximize profits at the expense of others (externalizing costs, moral hazards, shifting most administrative costs to providers, creating barriers to paying such as copayments, annual caps, deductibles, medical necessity, etc.). Based on their actual processes they have largely abandoned insurance (risk spreading) and devote most of their efforts to rationing care based on profitability.

Medical practices (but not psychological ones) are bought by hospitals to control the flow of their referrals, both in and out. Locally we see this vertical integration of health care provision and health insurance at UPMC and Highmark.

7. Notably absent from the juggernaut of healthcare is organized psychology which has failed to become a legally recognized “physician,” failed to convince decision-makers of the value of psychotherapy vs. drugs or of doing assessments, and is not seen as contributing much value in the integrated care/medical home/teamwork/capitated model. We, as well as the physicians, can be and will only employees with different job descriptions in the juggernaut of health care.

The Industrial-Medical-Big Pharma juggernaut spends hundreds of millions in lobbying and they would not do that if it did not work for their interests.

Why is all this happening?

Health care is the last major industry to be industrialized and industrialization has well recognized components and sequences.

• Standard parts: CPT Codes for services.

• Standardized labor: all laborers become “Providers.”

• Standardized processes: DRGs, manualized treatments, “guidelines,” “best practices,” and treatment plans. Weberian “rationalization” of the steps of all processes.

– Removal of outliers (psychologists) in costs (waste reduction) and performance (undocumented but asserted superiority).

– Professional managers (non-clinicians). Costs relentlessly being driven down, especially labor. (Remember why there were unions?)

And all the rest, just as industrialization hit gunsmithing by Colt in the 1790’s. Transportation with the gas engines in the 1920s. Farming with tractors and fertilizers in the 1930’s, etc. The Internet hit everything in the 1900.’sThe Industrial-Medical-BigPharma-Government  Juggernaut. Unstoppable. Inevitable. Technology and money drive our society and its structures and processes, not history, not ethics, not religion. If you are happy enough with eating all you food at McDonalds and buying all your stuff at WalMart, you will be satisfied with industrial healthcare.

What of the future for psychologists?

The first decision every clinician must make is to participate in healthcare or to go elsewhere. They are rapidly and unalterably separating and we have been trying to straddle them for years with our inventive combinations of income streams. Katherine Nordal said, “We have to be at the table or we will be on the menu.” Succinct.

I must recognize that there are possible ways to join healthcare while respecting private practice – Independent Practice Associations, for example – and I don’t know their local status.

Non-health care is all kinds of training (“skill-building”) using psychological principles (but likely not identified as “psychological”), therapy for those few who can afford our fees, forensics for those who must afford our fees, and a hundred other niches.

But I see the future of psychologists  as outside formal psychology. I call it FOPINIP for the ‘future of psychologists is not in (what is currently called) psychology.’ For example, behavioral economics is completely psychology. Computers are some hardware, some software, and a lot of design/interface/psychology. The Internet is all interface. Businesses love and need the social psychology of “leadership” which is either personality or small group dynamics, “succession planning” which  is family dynamics, positive psychology which speaks to “creativity” and “innovation,” and the decision sciences of “thinking smarter.” Politics is almost all psychology (influence, persuasion, small group dynamics, etc.) with a little economics.

No human activity is devoid of psychology and we are its experts.

I think on the horizon for the next decade is some potentially good news. Over the next decade we w ill see the implementation and integration into the juggernaut of the ICD-11 and the other ICs – International Classification of Functioning, Disability and Health; International Classification of Health Interventions; and IC for causations. Use of all of these together will close the circle from cause to symptoms to loss of function to treatment. Add in the full information on costs and outcomes and the actual monetary and human costs of prevention can be documented.

And much more I simply do not know about or understand.

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For twenty years Ed Zuckerman, PhD, has developed simple, practical, inexpensive, and transparently useful tools for his fellow clinicians.