Sunday, September 27, 2009

Reducing Mental Health Care expenditures without cutting services: some personal observations

It is simply unacceptable to me, and agreeably unfair to my readers that just over two months have flown by since my last entry in this blog. However, today I have made a firm commitment to resume regular blogging on current hot button topics of concern or interest to others.

Since my last entry I have learned a very valuable lesson worth sharing with others. But first, some necessary background.

For years I have struggled with episodic major depression and PTSD (Post Traumatic Stress disorder). In 1996 Social Security examined the depression with respect to its impact on employability. Based on their conclusion that I would be extremely limited in the types of jobs I could be considered for. Because these limitations would make it very unlikely that I would find employment in the area where I live, they granted my application for disability benefits. As is standard, two years later my Medicare eligibility kicked in.

Because my disability benefits are on the small side, I have also qualified for SSI, or Supplemental Security Income as well. For the disabled, SSI kicks in whenever the disability benefits fall below the minimum income amount allowable in each state. In states, such as Idaho, that have joint State/Federal Medicaid programs, SSI eligibility automatically confers eligibility for that program as well.

Major depression counts as both a medical and a mental health diagnosis. Thus, for several years I have been seeing a variety of counselors in addition to receiving what is called Psycho-Social Rehabilitation. In theory it is designed to be a one-on-one working relationship between a (supposedly) trained mental health professional and the client designed to improve the client’s ability to function more or less normally in all areas of life.

For several years I was assigned to an older PSR Case Manager who, on the surface came across as a laid-back, very personable person to be around. That is how he laid the snares with which he entrapped everyone he interacted with, employees as well as clients. It is only in the last month, now that he has retired, that I am beginning to recognize two things. First, the guy actually is a sociopath whose game is getting other people to tear themselves down physically, intellectually, spiritually and psychologically. Second, there is no area of my life that has not been severely damaged by his subtle efforts at promoting personal sabotage.

Four of the five counselors I have seen at one time or another over the last decade have been approved, either by this guy directly, or by the agency that he nominally managed. The last three, in fact, were employees of his agency. This is where the cautionary tale comes in.

With hindsight, I am seeing the extent to which everyone who is seeing a counselor, or is working with any kind of mental health professional, needs to stay on guard by staying in close contact with your innermost feelings. With counselors, remember, you are the consumer, so you are in charge. If you feel (or can see) that you are not making satisfactory progress, or if you sense that the counseling process is leading you in a direction you are not comfortable with, drop the counselor after being open about what you are feeling that you don’t like.

I decided to end the weekly sessions with the last counselor in my chain at the end of June of this year. In the three months since, in several areas of my life I have actually made more progress than I had in the last three years of counseling. Why? All a counselor can actually do is make suggestions about things to try, and, perhaps, point you in a direction to follow. All of the actual work in a counseling relationship ultimately is done by the client, not the counselor.

These thoughts segue into the health care debate here in the US in a very direct way. Everyone, from President Obama on down, is openly talking about the need to eliminate waste (and fraud) from the US health care system. Mental Health is one area of health care where waste and fraud are notoriously rampant. Counseling sessions that continue for years without seemingly making progress are a drain on the health care system that need to be reigned in. Making it easier to weed out mental health practitioners who are professionally unqualified or who are ethically challenged is one very cost effective fist step in wringing the fraud and waste out of this area of health care.

Did I need to see a succession of counselors for the better part of the last eight years? At one time, I would have said I did. Now, however, I readily see that at least the last two years of counseling could have been eliminated, saving Medicaid a chunk of money while leaving me better off sooner rather than later. However, with the last three counselors I was under definite pressure to keep the counseling going from this guy I mentioned. Why? My PSR agency also employed the counselors I was seeing, so it was in the agency’s best interests that the counseling continue, whether it was doing me any good or not.

The Medicaid program itself is in serious need of reinventing from the ground up. Currently it is too easy to gain eligibility for benefits and then cruise on them for literally an indefinite period of time. In Idaho, Medicaid shows little to no interest in helping clients improve any area of their health. This is where a lot of the waste in American health care comes from: Medicaid and private insurance plans that openly block access to preventive health care procedures and screening tests that would head off more costly (and more serious conditions) later on.

One concluding thought: given this insurance industry opposition to cancer screening tests (until, in too many cases, it is too late for the patient), how many women have been either needlessly permanently disfigured, or have died prematurely from breast cancer that could have been prevented had it been detected early enough?

1 comment:

Samantha said...

Wow. I'm sorry. I have, over the last six years seen sides of the health community that scare me, and leave me scared. By the same token, one of the biggest reasons I am alive is because I have managed to get some help staying that way.

I too am on SSDI. PTSD and Major Depression issues after being a battered wife. I'm "lucky" in some respects that I have to much SSDI income to qualify for SSI, but it also means I'm barred from Medicaid. Between that, and the current attitudes toward health care, I'm NOT actually seeing anyone currently because of two things. My out of pocket costs for care, and because I'm not even close to strong enough to have to start over with someone new. That doesn't even take into account finding someone good.

So my GP continues my meds and tries to encourage me to find someone else for mental health. And I remain kinda stuck because Medicare has some pretty odd rules for mental health. Plus the Humana plan that I had to change to when I moved from Jersey to Ohio screws things up by making "specialists" WAY more expensive in terms of both co-pay and deductible that I cannot afford things. It's a racket.

Now with swine flu sweeping the globe, the LAST place I want to go is a health care facility of any kind. So I stay home (I'm really good at that, now that I have a home) and stay out of trouble. I grocery shop at three in the morning because there is almost no-one there, and I can self checkout. I keep sanitizing hand wash close by, and use it regularly. Oy, such a world we live in eh?

To be fair and honest, I was blessed with my last therapist. She was awesome, and to this day remains a good friend. She retired and I moved. Had to move, had no choice, but that was a really good move. But replacing my therapist and pdoc, not such an easy task. And now one that is seriously on hold. I'm thankfully no Adrian Monk, but I spent too many years working in and around medicine to know that going near the front line right now would be stuoopid!