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While I have been inspired by some of my colleagues, the government and certain organizations during the pandemic, I have also been profoundly embarrassed.
I left semi-retirement in December 2019 to assist in addressing the adolescent suicide crisis, only to be faced with the pandemic. Surprisingly, I found returning to practice in Minnesota akin to practicing in a Third World country, with unacceptable shortages and delays. Not due to lack of financial resources or infrastructure flaws, but rather due to corporate greed and corrupted politicians.
Additionally, we have too few clinicians. The shortage of psychiatrists has increased every year since I completed my training in 1988 and will continue to do so. No one in their right mind would consider a career in psychiatry given the current state of affairs, at least not in Minnesota.
Years ago the Legislature made some insurance plans illegal in Minnesota. Overnight you could purchase better insurance at a lower cost in adjacent states, which created a relative monopoly that led to our current situation. A child or adolescent in need of inpatient mental health care could spend days in a holding room and ultimately be hospitalized hundreds of miles from home. Some plans have no formulary drugs for attention-deficit/hyperactivity disorder (ADHD). Antidepressants that have been available generically for decades are on no formularies. Of the three new “wonder drugs” for bipolar disorder, only one is on any formulary, and it becomes generic in February. The drugs have different mechanisms of action. A single agent does not work for everyone.
Ever-changing rules that limit quantity, dosage or formulation appear weekly. I am spending as much time each week fighting with insurance companies for coverage as I am treating patients. Imagine the cost savings if medications were simply provided without an army of workers tasked with delaying or denying their approval to save, sometimes, only pennies.
As a psychopharmacologist, I have the expertise to determine which medication(s) are indicated and safest for my patients. Insurance companies prefer more dangerous or ineffective strategies or multiple drugs simply because they are less expensive.
Cumbersome contracting and credentialing that takes months also delays access to care. We have a Board of Medical Practice that monitors the quality of medical care in Minnesota. Documentation of training in claimed field of expertise and a medical license in good standing, which would take 48 hours to verify, should be the only requirements, not months of applications and reviews. One company took months to complete this process, then added a further delay of 60 days before I could see their patients. Another sent a letter to the parents of my patient (a child) suggesting an alternative contracted provider in a neighboring community who did not see children. Insurance companies pursue the illusion of adequate care, a list of contracted providers or statements that drugs are on their formulary, but without actual coverage.
The Legislature created this problem. One might presume it also could provide the remedy, but I sent a letter to all of my senators and legislators, local and national, months ago without a single response, even from my local representative.
Make no mistake: Insurance companies are interested in two things — profit margin and public perception.
- Standard insurance benefits with no unfathomable deductibles that render the policy essentially only catastrophic coverage. “Medicare for All” is a frightening prospect. I have Medicare, the only insurance that requires two additional policies to remain improved but substandard. There was a time when “Medicaid for All” might have been appealing, but with the carve-out from standard Minnesota Health Care Programs to a host of alternatives (UCare, Blue Cross Blue Shield, etc.), they all have the same problems as commercial insurance.
- Inclusion on the formulary of all FDA-approved drugs (approved for any indication). No dosage limitations (in milligrams, pill count, intermediate dosages or formulations). No prior-authorization requirements or formulary exceptions for FDA-approved drugs. Compensation for services that would foster the development of new inpatient services.
Outcome: Improved quality and efficiency of mental health care with some reduced profitability of insurance plans (but they can afford it). The Blue Cross Blue Shield CEO recently took a pay cut, to $12 million.
Open the market to competitive companies and plans — that’s how capitalism works. Health care costs are a legitimate concern, but not at the expense of quality of care.
dr Richard O. Walker Jr., of Wanamingo, Minn., is a psychiatrist.