Abundance over Scarcity

This entry was posted in Value Based Medicine on by .

Abundance over Scarcity. It makes sense, it’s good for patients and it’s good for business.

For those in the business of treating people who struggle with addiction and mental health disorders, we know just how competitive the space has become in recent years. As demand for treatment has skyrocketed due to factors such as the various benefits of the Affordable Care Act, the mental health parity law, decreased stigma and the publicity that comes unfortunately from the opioid epidemic, new entrants have aggressively entered the business in order to capture this increased demand. In 1986, for instance, there were about 400 treatment centers servicing those struggling with addiction. In 2016, there were ~14,000. Revenue for treating addiction was estimated at 9 billion dollars in 1986. In 2016 it was estimated at 34 billion dollars. The industry has skyrocketed. Though margins may not be what they are in other areas of medicine, the treatment center business is booming and competition for that business is fierce.

According to some statistics, Addiction and Mental Health are Western Society’s largest public health care problem. In 2013, it is estimated that Americans spent over 200 billion dollars treating mental health conditions, more than any other condition including heart conditions, trauma, cancer and diabetes. Behavioral health disorders are the leading cause of disability in the US and Canada, with 1 in 5 adults in the US experiencing a serious mental illness in a given year that substantially interferes with or limits one or more major life activities. Even so, more than one in three adults with serious impairment received no mental health coverage in the past year, with less than one third of adults with mental health disorders who do get treatment and receive care considered to be minimally adequate.

Despite the massive increase in number of providers seeking to fill this need, trust-worthy, high quality programs who practice truly evidence based treatment are few are far between. Many new entrants have entered the field just for the money. Others have entered with the best of intentions but without the training or knowledge required to treat our nations “largest public health problem”. Further, there is a massive shortage of psychiatrists who are needed to run these programs and who are bound by the obligations of their medical license and of course the age old Hippocratic Oath. According to the 2017 Review of Physician and Advanced Practitioner Recruiting Incentives, Psychiatrists are now the second most highly recruited physicians after family physicians. The problem is so bad that some treatment centers have a once per week psychiatrist fly in from another state just to “sign off” on medical charts in order to retain the center’s licensing and accreditation. Just here at SCH, we receive at least 10 calls every single day looking for “a psychiatrist”. More are needed, and desperately so!

With all of this demand and a shortage of suppliers, one would think all of us in this line of work could approach treatment from the perspective of abundance rather than scarcity. Since there is plenty of business for all of us:
1. let’s work together, 2. let’s compete but compete ethically and fairly with transparency and reliable and standardized outcome measurements, 3. let’s be honest with our patients and 4. let’s always try and do what is in the best interest of the patient as opposed to what is in the best interest of us. Seems simple, but unfortunately not always the case.

When a patient comes in for a higher level of care and they ask a question such as, “Can I please continue to see my outpatient psychiatrist while I am here?”… The answer should be “Of course you can… Our apologies to you on behalf of the entire industry that you even feel you need to ask that question!” There is never enough love, compassion or care for patients struggling with these illnesses. Excluding anyone from a patients care team should never be done for any reason other than because clinically it is not appropriate. Never, even if you are afraid you may “lose” the patient to another provider. Luring patients in with photos of swimming pools, fancy homes and gourmet meals doing nothing but implicitly encouraging people to use their health benefits as a means to take what ends up being a vacation isn’t ethical and it isn’t fair. It’s not pair to patients and it’s not fair to those providing quality care without this superfluous stuff that does not help treatment. Definitely stop brokering patients for dollars. This is doing nothing but making the industry smell like a rat. Make referrals to facilities that can support what the patient may need, but doing so in exchange for money is full of inherent conflicts of interest, and it also happens to be illegal! When a patient asks what the “success rate” is for treatment, be honest with them. The answer most likely is “unfortunately, we don’t know” but if they push first ask them what they would define as success and if you have that specific data and it is reliable and statistically significant make sure to tell them you still really don’t know because the self-reported post discharge data is not as reliable as we would like it to be. When asked by a patient to compare your treatment center with another, be honest and tell them once again that unfortunately because of the lack of standardized outcome measurements in the field, there is simply no objective means to compare one facility against the next. Tell them many of us hope this will change in the near future, and that you are doing all that you can to collect data and share that data with your interested constituents as they seek to implement standardized outcomes in the desperately needed shift from fee for service to value. Lastly, when a patient needs something that you don’t do or that you think someone else may do better, refer that patient to that other provider. When we all are measured based on our patient’s outcomes as opposed to the quantity of services that we provide, and our success is directly aligned with the success of our patients, we will be incentivized to treat those who we can actually effectively and send the rest somewhere else. In the meantime do it because it will help you sleep at night.

When an industry is shrinking and the good ole days are numbered, one might expect to see a mindset of scarcity over abundance. However, such is not the case with the business of treating addiction. Treating people with core principles such as abundance, transparency, honesty and collaboration is good for patients and it is good for business. Most know this. The rest should change their practices or exit, and let the rest of us compete based on what we do and our how we actually perform.