A comeback for Dr. Freud

Monday, March 27, 2023

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Investigation finds huge gaps between payment rates for mental health care and all other conditions

Like many states, Minnesota’s mental health system suffers from a lack of capacity at almost every level. There are too few psychiatric hospital beds, step-down facilities and non-hospital programs. The result: People get pushed into overcrowded emergency departments or wait weeks or months to get treatment. And while the causes are complex, the biggest factor, according to a detailed investigation by the Minneapolis Star Tribune, is the low reimbursement rates paid by health insurers to hospitals and mental health facilities.

Reporter Christopher Snowbeck dug into the financing of mental health in the Land of 10,000 Lakes (but one-tenth as many psych beds) and found striking discrepancies in rates paid to hospitals for treating patients with psychoses, compared with every other health condition. Using price information disclosed by hospitals and insurers as a result of new federal legislation, the newspaper compared rates paid by commercial and Medicaid managed care insurers for the 20 most common categories of hospital care. With both types of insurance, expenditures for treating substance abuse and psychosis ranked 19th and 20th, respectively.

Private insurance plans reimbursed hospitals a median of almost $4,000 a day for treating seizures, lung disease, pneumonia, heart failure, digestive disorders, nutrition/metabolic disorders, septicemia, renal failure and respiratory failure – but only about $3,000 a day to treat alcohol and drug abuse and $2,000 to treat psychoses. Insurers operating Medicaid managed care plans paid a bit over $2,000 a day for patients with each of these conditions, but less than $2,000 for alcohol and drug abuse care and around $1,300 for patients experiencing psychoses.

There is a glimmer of hope: Legislation passed in recent years created Minnesota’s first three psychiatric residential treatment facilities for children and adolescents with serious mental illness and trauma that will eventually include 300 beds at six locations. The first to open, a 48-bed nonprofit, has treated over 200 kids since 2018 with an average length of stay last year of more than seven months. But the wait list still extends for months. Medicaid HMOs will cover the cost but only one commercial insurer has so far been willing to do so.

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Not Your Daddy’s Freud

The Instagram account freud.intensifies has more than a million followers. “Freud’s Last Session,” starring Anthony Hopkins, is currently being filmed in a reconstruction of Sigmund Freud’s famous study. Prominent psychoanalytic institutes say applications from people wanting training in analysis are on the rise. Some 40 years after psychoanalysis faded from a prominent place in American health care, “young (or at least young-ish) people are rediscovering the talking cure, along with the ideas of the Viennese doctor who developed it at the turn of the 20th century,” according to the New York Times (from which we borrowed this item’s irresistible headline).

Psychoanalysis plumbs the psyche to identify subconscious causes of human behavior. Its demise had many causes, according to a 2019 column in Psychology Today, including the rise of modern psychopharmacology – the medication cure – and of managed care cost-reviewers. The notoriously high cost of analysis (a senior analyst in Manhattan can charge up to $400 an hour) and its reputation for elitism and even racism didn’t help. Today, analysis has democratized a bit. While analytic institutes once limited training to medical doctors only, psychologists, social workers and even people from creative or literary backgrounds can now pursue psychoanalytic training.

Critics have argued for years that psychoanalysis doesn’t work. Today those arguments are undercut by data showing mixed evidence for the effectiveness of antidepressants. Views of Freud himself have also evolved. With the rise in feminism, he was labeled a sexist for his concept of penis envy and a homophobe for his suggestions that homosexuality in men stems from their “fixation” on their mothers. Now, the Times points out, you can see a defense of Freud on TikTok, where a user cited a famous  letter from Freud. “Homosexuality is nothing to be ashamed of, no vice, no degradation,” Freud wrote in 1935. “I don’t know how the idea that Freud hated gay people got started,” the TikTok user concluded, “But he did not. He absolutely did not.”

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Do medical boards really need to probe doctors’ mental health history?

No, says the American Medical Association. Doctors have complained for years that state licensing boards, credentialing bodies and liability insurance carriers ask intrusive questions about whether doctors have a history of mental illness of substance use – and that these questions discourage physicians from getting treatment.

An article posted on the AMA’s website says that the Joint Commission – which accredits hospitals – and the Federation of State Medical Boards “strongly encourage” these bodies “to refrain from including these types of questions when collecting professional information from clinicians for credentialing, privileging or other purposes.”

The article also notes that even though doctors have higher rates of depression, burnout and suicide than the general population, “about 40% of physicians would be reluctant to seek mental health care because they would be concerned about the repercussions to their medical licensure.”

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The rise and fall of a digital mental health darling

Mindstrong Health displayed all the signs of a trailblazer with a hot new concept. The mental health startup would passively analyze the tapping, typing, and scrolling patterns of mobile phone users to identify early signs of cognition and mood changes. These “digital biomarkers” would serve as high-tech “smoke alarms” and help predict the onset of mental health issues like depression. The company launched in 2014 with a goal of doing for mental illness what blood glucose testing has done for diabetes. Over time, it raised $160 million from Silicon Valley investors.

Now the company has fallen apart in spectacular fashion. Stat, the health news and technology site, examined its rise and fall and found a familiar pattern: A company with grand, unrealistic ambitions, tried to do too much too fast and changed its narrative when its original mission could not be fulfilled. Mindstrong inked contracts with providers and payers – including a partnership with the Los Angeles County Department of Mental Health – on the promise of that technology. But its groundbreaking functions were never fully developed.

Now, two months after laying off most of its employees and permanently closing its Menlo Park offices, Mindstrong is selling its technology for parts to the online therapy platform SonderMind.

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In other news…

Fifteen months after issuing a report warning that mental health challenges were leading to “devastating effects” among young people, Surgeon General Vivek Murthy has been crisscrossing the country to highlight the issue, much as his 1980s predecessor C. Everett Koop did for the dangers of smoking. “I think of mental health as the fuel that allows us to show up for our communities, our friends, our family and our lives. And when that fuel tank is low, it compromises our ability to be who we can be in our best moments and to show up at work or in school,” Murthy told the New York Times in an extended interview.

Caregivers should deal with their stress − before it turns into burnout.

For more than a third of the 53 million unpaid family caregivers in the U.S., the emotional, mental and physical impacts of caring for a disabled or infirm loved one can become so overwhelming, it leaves the caregiver feeling stressed – and sometimes on the road to burnout. HealthDay offered an abbreviated guide to recognizing the signs of caregiver stress – and some tips for managing it.

Barriers to mental health care in Florida are nothing new.  A scathing report released earlier this year by a legislative commission described numerous problem that made it hard for people to get the mental health care they need. But the findings aren’t new, according to a story by Kaiser Health News. Twenty years ago, the Florida Legislature set up another commission to examine the same issues and publish recommendations. It did – and that was pretty much the end of it.

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If you or someone you know is in crisis or experiencing suicidal thoughts, call or text 988 to reach the 988 Suicide & Crisis Lifeline and connect in English or Spanish. If you’re a veteran press 1. If you’re deaf or hard of hearing dial 711, then 988. Services are free and available 24/7.

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