Yesterday, July 2, 2015 I gave credit to a medical innovator and systems analyst, a physician, and a plastic surgeon, at that, at Henry Ford Macomb Hospital in Clinton Township MI, Dr. Vikram Reddy MD MAHS who as medical quality of care director of the hospitl, wrote in the Free Press and Bridge Magazine there locally of his pilot project to try to address the long standing, not improving problem of “frequent flyer,” high cost, not resolving ER patients that represent one of the growing and worst public health care crises in this country that plague every hospital in the USA large or small. He is making a superb effort to organize, energize, find and locate appropriate medical management services for these problematic medical consumers who seek highest cost care in the most inappropriate place, the hospital ER. This relates to many nationwide problems growing since the Reagan years that I will refer to later. But Dr. Reddy is trying an approach being looked at nationally as a solution to this issue, i.e., diversion/referral to appropriate services outside the ER that do much more good, are able to give these patients long term, continuing, consistent disease management that they need and deserve and that is where the healthcare dollars are really saved while at the same providing health maintaining and promoting care, care that prevents relapse of their conditions, and keeps them from going into crisis and having to seek inpatient care which is usually at least 10 to 20 times the cost of outpatient care. Now don’t you think that would motivate the planner and governments to seize upon these sensible solutions? “Not hardly” as they say here in the South.
Who are the patients? They can be easily identified as falling in approximately these groups: (and I apologize right now if my brain leaves out/omit significant groups as I will comment upon those I know and see the best and most and may omit others); 1) the drug prescription abuser/addict who has or utilizes inappropriately a pain condition to repetitively doctor shop, and nowadays “ER shop,” in order to gain more prescriptions for opiates, to abuse until they run out and start all over again at the same or a different ER: 2) the chronic substance abuse who is not in recovery whether having been in “starter” substance abuse programs, like inpatient detox program/units, or AA/NA etc., and come in for acute treatment of intoxication and consequent often legal problems (assaults, disorderly conduct, impulsive threats while “out of their (rational) minds making temporary suicidal or homicdal or assaultive threats, or for worsening of many extremely serious comorbidities [accompanying serious recurrent medical problems from continued substance abuse: delirium, worsening of liver disease going into cirrhotic crisis, hepato-renal renal failure, bleeding from the esophagus’ enlarged “varicose like” veins, acute pancreatitis, comatose states from alcohol poisoning or just plain old overdosing on sedating, respiration suppressing drugs ranging from opiates to anti-anxiety medications like Xanax, 3) the young adult who is developmentally disabled and psychiatrically ill who goes into acute psychiatric crisis, assaults their parents for no reasons, becomes destructive, leaves the home and starts dangerous behaviors like wandering in the woods and on the sides of high speed highways; and lastly 4) the mentally ill who come from homes, the streets, shelters and now ever increasing from the local jails, in acute psychotic crisis and demand immediate attention as much as patient having a myocardial infarction in progress.
So that is what Dr. Reddy is facing in his hospital in Clinton Township MI. Where did this start in Michigan? It started in the recession of the 1980’s when the Big Three automakers were really losing business to the foreign carmakers, especially VW and the Japanese brands who were building better quality cars, that were more efficient and cost less. As the American auto industry suffered massively so did Michigan since guess what? Michigan was ill suited to weather economic change ever if it were positive and revolutionary. Its economy like so many states in the South who suffered even more for even longer, was not diversified; it was based largely on manufacturing with a huge percentage of the machine shops all over SE Michigan serving the auto industry, and agriculture. Tourism, the state higher education university system and big time sports helped but not that much in reality. So the state had to cut revenues and one of the places it placed emphasis upon was the mental health cost center of the state government. Gov. Engler as is known slashed services all over Michigan and by 2000 was planning to privatize the entire system to get the state out of the mental health business which had become an article of faith by then at the National Governors’ Conference in those years. “Cut and Privatize Mental Health.” Nowadays the new mantra is to dismantle the state employees’ unions and workers’ associations and somehow transmogrify a pretty dedicated work force in the McDonald’s restaurant model of the not long term, disposable, LOW paid employee.
By 1999 and certainly by 2000 the Detroit Free Press had been running a series of articles on the dismantling of the mental health system since approximately 1992 or thereafter as the “privatization” ethos of those times from the era of Reagan deregulation as the solution to labor problems and inflation had taken hold of many politicians and policy planners, mostly of the Republican persuasion.
Ms. Wendy Wendland-Bowyer in the early 2000’s for the Free Press did creditable reporting on this evolving issues for a number of years. An example of an article of her, “State to unveil new plan for mental health system,” is a great example. In this she notes indirectly that at that point in time she state was having to “reverse” itself and retreat from its full privatization plan. This article ran on Sept. 1, 2000. But it noted the overriding principal was to convert the county mental health center based systems all over the state to full private competition in which privatized for profit mental health care provider business entities would eventually take over the delivery of mental health care. This was coming after the decade in which Gov. Engler had closed several state psychiatric facilities, Pontiac State, Clearwater, etc. She wrote: “the first phase of the waiver [a permission process from the Feds to do all this] required county mental health agencies to be run like manage care plans. The second phase was to open the county services to private competition.”
There was a feature based on population density, designed to promote business efficiency that has been coped in almost all states by now to eliminate small, supposedly inefficient service units in counties with sparse populations. “The new plan does require that county agencies meet certain goals in order to avoid private competition. For example, the agencies must have at least 20,000 Medicaid recipients in the geographic area – something 12 to 14 of the state’s 49 agencies have…” Of course the unforeseen consequence to this rule, was that with regional “centralization” of mental health centers usually into the county with the largest population of the several that had merged, services access became distant in all these mini-catchment areas for nearly a majority of clients, forcing them to travel longer distances to their ordinary appointments. Compliance went down, more appointments were not kept and guess what, clients ended up in ERs by the hundreds suddenly to all the bean counters’ surprise and have now been perplexing and occupying people like the good Dr. Reddy of Clinton Township with how to fashion a local solution to what is a state imposed system error.
I will apologize at this point. I have included the link to Ms. Wendland-Bowyer’s article, but it is hard to reach and you have to do some real “Search Box” or “Archive” searching to find it on the FREEP website as in the ensuing years the newspaper’s digital online edition has archived or taken down many many of the articles from that era. My sincerest apologies if it is no longer available.
In my next post on the history of the mental health plans and crises in Michigan, which serves as instruction and one of the true original examples for what has and is happening in most of the other states in this country currently, I will talk of the defunding issues of other sectors of the mental health care delivery system that the non provider, ordinary observer would not likely think of, nor realize who vitally important they are and always have been, and what enormous negative consequences they have also had behind the scenes further worsening the dumping of the mentally ill into systems that are not designed to adequately care for them.