The Harvard Neuropsychiatry Course

I went to the Harvard Neuropsychiatry course for all of the wrong reasons.  I started going to HMS courses in Boston back in the late 1980s.  I have always seen myself as a medical psychiatrist knowledgeable in neurology, medical imaging and electroencephalography.  I have always liked seeing people with complicated problems that are associated with psychiatric diagnoses or who have psychiatric symptoms associated with their primary medical or neurological diagnoses.  That led me to the Behavioral Neurology courses through Harvard where the presentations were done by all of the experts at time including M-Marcel Mesulaum, Antonio Damasio, Hanna Damasio, Elliot Ross, and David Bear.  Their work is well represented in the text Principles of Behavioral and Cognitive Neurology.  At the time there were some older neuropsychiatry texts but learning about the field generally had to occur on a reference by reference basis.  I was working in a Memory Disorders and Geriatric Psychiatry Clinic and learning neuropsychiatry on a syndrome by syndrome basis.  I did not find out until this course that it is the largest meeting in the field and has been occurring on an annual basis for the past two years.  My motivation for coming was basically to see whether I missed anything.  I always need to answer the question: "Can a clinician working too many hours per week keep up with a technical field to an acceptable degree."  For the first time ever in my career I was spending a lot of money on a conference and travelling well outside my comfort zone to see presenters who I did not know that well.

There were about 320 people registered for the course.  The setting was a hotel built in the early 20th century but extensively remodeled to 4 star hotel status.  The conference itself took place in the main ballroom and it was densely populated with some overflow into balcony seats and a mezzanine area in the back.  The audiovisual effects worked with with a large projection screen over the speaker and large LEDs TVs lining each side of the ballroom.

The  overall format of the course was to present a lot of technical information on Day 1 and discuss more discrete diseases and syndromes on Day 2.  The detailed agenda for both days can be found at this link.  Day 1 was a focus on neuroanatomy, functional brain networks, neuroimaging,  neuropsychiatric and neuropsychological approaches to the complex patient, and a detailed approach to the complex patient.  These were not TED talks.  The first three presentations covered 81, 60, and 60 slides.  That is the way I like it.  An additional benefit is that all of the PowerPoints were available in PDF form online.  Even the most unreadable slides are easily visible in this form.  The PDF form is also allows the syllabus to be printed in black and white and used primarily for note taking.  Legibility of the slides depend on the print size and many in this syllabus were unreadable.  I think that all conferences should use this approach.  I would like it modified so that the original slides could be reused in lectures by Creative Commons licenses.

The early lecturers used a lot of subordinate clauses and very long sentences.  I could imagine that anyone unfamiliar with the jargon could get lost.  The lecturers were unapologetic and one of them suggested studying the slides and references to get up to speed.  The pace of the course was intense with brief coffee and lunch breaks in order to cover the advertised CME.  Several of the lecturers ended up accelerating their presentations as they realized that they were running out of time.  My focus in these conferences is on information transfer and not style points on the lectures.  At that level I consider it a success.  Key points were highlighted as well as references.  There were a couple of graphics that were not referenced.  The syllabus for the course is 453 pages long and could easily be worked into a text at some point.

In the past, I have reviewed all of the lectures at conferences.  For this conference I am going to mention a couple of high points.  There is some confusion about what neuropsychiatry is.  Barry Fogel, MD defined it at the end of Day 1: "Neuropsychiatry is a branch of clinical neuroscience more than a mental health discipline.  It is always in the context of the brain."  Every lecturer maintained that theme reviewing key brain circuits involved in pathological states including some that were considered to be functional as well as states associated with clear brain pathology.  In some cases those formulations were associated with a new conceptualization of the disorder.  A good example, is the case of traumatic brain injuries (TBI).  Tom McAllister, MD made the point that not too long ago, nobody would have showed up for a lecture on TBI.  Those were the days when it was common to consider TBIs, especially occurring in sports to be minor events.  That has been reconceptualized from the perspective of neuropathological changes, protein markers (Tau, APP, Aβ, and others), and possible progression to dementia.  The treatment of neuropsychiatric syndromes of TBI including depression, PTSD, and other psychiatric syndromes.  I am used to seeing a lot of people with bipolar like syndromes after TBIs but that was not mentioned.  Excellent reconstructions of the brain with a map of the results of a large number of TBIs were presented with an emphasis on the circuitry affected and how that can lead to symptoms.

When I think about earth shaking information on a single slide (yes - it can happen) - the best example I can think of was a slide in the presentation: Neuropsychiatric Aspects of Frontotemporal Dementia by Brad Dickerson, MD.  For anyone who has followed it, the diagnostic approaches to this relatively common dementia have been confusing over the years (2).  In a slide FTLD (Frontotemporal lobar degeneration) clinicopathological spectrum parses the 6 major clinical  syndromes into subtypes based on biological markers.  Each category was also color coded to indicate the degree of tauopathy.  I found a modified version of this slide in an article by Irwin, et al in Frontiers in Aging Neuroscience (1).  These same authors have published a significant number of the papers in the field.  This review stood out to me because it is the clearest conceptualization of FTLD that I have seen.

The second high point of the conference was on Functional Neurological Symptom Disorder (FNSD).  This is actually a subheading under Conversion Disorder in the DSM-5 (p. 318) and the main diagnosis is the disorder known to most psychiatrists.  The disorder is one of pseudoneurological symptoms like weakness, paralysis, sensory symptoms, speech problems, or seizures with no known correlates of the medical diagnosis.  The presentation by Gaston Baslet, MD on the approach to these disorders was very informative.  Rather than take a strict DSM criteria approach, he presented the criteria and then illustrated levels of diagnostic certainty - the levels of diagnostic information that are ideal versus what is clinically available.  The example given was for Psychogenic Non-Epileptic Seizures (PNES).  The increased prevalence of these disorders in neurological practice as opposed to primary care was noted.  Most importantly, the approach to treating the disorder was discussed as well as what seems to work.  A model of predisposing, precipitating, and perpetuating factors was presented.  Like most disorders, cognitive behavioral therapy (CBT) is a useful treatment modality either as psychotherapy delivered in a  standard approach or using a self help manual.  Dr. Baslet also discussed a communication protocol on how to present the diagnosis and rationale for treatment to the patient.  Limiting factors include the low number of patients who complete treatment and there is a spontaneous improvement rate of about 20%.  A neurobiological model of PNES/FNSD was presented based on the work of van der Kruijs, et al (3).  This is important work for any psychiatrist who has not had the experience of treating PNES/FNSD on an ongoing basis with psychotherapy.  My experience is consistent with the presentation in that it takes good communication with the patient and an effective model for therapy to get results.

Forced normalization epilepsy was a term that I was unfamiliar with even though I have treated a significant number of people with seizure disorders.  It was discussed in Gaston Baslet's second presentation on the Neuropsychiatry of Epilepsy.  It is a description of a syndrome where psychotic states occur as the EEG abnormalities of the seizure disorder improve or disappear.  The neuropsychiatric symptoms that emergence when this occurs is also referred to as alternate psychosis.  There is a small but significant literature on this problem that also highlights some of the controversies.  His presentation also discussed the safety of antidepressants in epilepsy and the FDA warning on suicidality and antiepileptic drugs (AEDs).  Since I prescribed a lot of gabapentin in the treatment of addiction, anxiety, and chronic pain - that is a warning that I have to address a lot with patients.  He showed the Forest plot of odds ratios for specific AEDs and according to that reference (4) some drugs may be protective for suicidal ideation and behavior.  With the discussion of emerging and interictal psychotic symptoms an equivalent brief discussion of antipsychotic drugs in these states would also have been very useful.  Dr. Baslet also mentioned one of my favorite neuropsychiatric symptoms Alice In Wonderland Syndrome or metamorphopsia as it is sometimes known.  Like Alice, patient's experience body distortion (feeling too tall, floating, sinking into the ground) as a manifestation of infectious disease (originally Epstein Barr Virus), migraines, or epilepsy.

A  final brief point was noted in the presentation on neuropsychology by Aaron Nelson, PhD.  It is useful at a time when I think there is a lot of controversy about these assessments and what they show.  The commonest reason I see patients getting a neuropsychological assessment these days is Attention Deficit-Hyperactivity Disorder.  It is generally presented to me as proof of the disorder and proof that a person needs stimulant medications.  The patient generally reports that they were "tested" for ADHD and found to have it despite a normal development history, normal and typically good academic performance, and good vocational achievement.  I have previously posted that Russell Barkley, PhD one of the leading authorities on ADHD has stated that neuropsychological testing is neither necessary or sufficient to make a diagnosis of ADHD and as it is based on clinical criteria.  Of course the main reason for neuropsychological testing of individuals suspected of having ADHD is to test for any associated learning disorders and in the adult patients I see - very few people recall any information of that sort.  Dr. Nelson points out that intraindividual variation in neuropsychological test performance is common with 66% or participants in his study (6) producing maximal discrepancies that exceeded 3 standard deviations on test performance.  His conclusion is that score variability alone is not enough to base diagnostic inferences on.  Dr. Nelson also called for a show of hands to see if any clinicians had access to neuropsychological testing in a time frame of less than 3 months.  There were few if any hands raised.            

Those were a few of my favorite highlights from this conference.  There are many more, but I am trying to keep this post contained to the highlights and overall focus.  This is an intense conference but a good one.  In the follow up assessment, they asked if the course should be three days rather than two and I endorsed that approach.  I think that the inflammatory section of neuropsychiatric disorders could be reinforced by having any of the psychiatrists who write the sections in Lahita's text on Systemic Lupus Erythematosus present on that topic. If your priorities in conferences are similar to mine (information transfer, non-experiential, and a direct comparison of your skills to the experts are a priority) - you might want to attend this conference next year.  The course organizers did have question and answer sessions regularly throughout the program and questions were actively solicited by course staff and read and answered by the lecturers.

And it turns out my approach to self-study has paid off.  There were several points where I could have stood up and given the lecture.  That may seem immodest if you believe that practicing psychiatrists need to be constantly tested and reassessed by some higher authority to prove that they are competent.   I don't and never have.  It turns out all you have to do is practice medicine, think a lot about what you are doing and try to keep up on the literature.  At one point the lecturers asked about how many people in the audience were psychiatrists and then how many have treated people with frontotemporal dementia.  Most of the people were psychiatrists and most of them have assessed and treated frontotemporal dementia, despite the fact that the diagnostic classification has been in a state of flux for the past 20 years.  Thinking about that, there was a tremendous amount of knowledge about neuropsychiatric disorders in that room.  I can't imagine that this disorder or the general importance cerebral atrophy on imaging  is well recognized in primary care settings.  That is just one of the reasons why neuropsychiatrists are needed out there and why these concepts need to be taught and understood in residency training.



George Dawson, MD, DFAPA
 
 

References:

1:  Irwin DJ, Trojanowski JQ, Grossman M. Cerebrospinal fluid biomarkers for differentiation of frontotemporal lobar degeneration from Alzheimer's disease. Front Aging Neurosci. 2013 Feb 21;5:6. doi: 10.3389/fnagi.2013.00006. PubMed PMID: 23440936; PubMed Central PMCID: PMC3578350.

2:  Kertesz A, Munoz DG.  Frontotemporal Dementia; in:  Alzheimer Disease. RD Torrey, R Katzman, KL Bick, SS Sisodia (eds); Lippincott Williams and Wilkins; New York; 1999; pp 133-145.

3:  van der Kruijs SJ, Bodde NM, Vaessen MJ, Lazeron RH, Vonck K, Boon P, HofmanPA, Backes WH, Aldenkamp AP, Jansen JF. Functional connectivity of dissociation in patients with psychogenic non-epileptic seizures. J Neurol Neurosurg Psychiatry. 2012 Mar;83(3):239-47. doi: 10.1136/jnnp-2011-300776. PubMed PMID: 22056967.   JNNP has a collection of Neuropsychiatry articles up until 2015.

4:  Hesdorffer DC, Kanner AM. The FDA alert on suicidality and antiepilepticdrugs: Fire or false alarm? Epilepsia. 2009 May;50(5):978-86. doi: 10.1111/j.1528-1167.2009.02012.x. Review. PubMed PMID: 19496806.

5: Hesdorffer DC, Berg AT, Kanner AM. An update on antiepileptic drugs andsuicide: are there definitive answers yet? Epilepsy Curr. 2010 Nov;10(6):137-45. doi: 10.1111/j.1535-7511.2010.01382.x. PubMed PMID: 21157540.   

6: Schretlen DJ, Munro CA, Anthony JC, Pearlson GD. Examining the range of normal intraindividual variability in neuropsychological test performance. J Int Neuropsychol Soc. 2003 Sep;9(6):864-70. PubMed PMID: 14632245.



Attribution:

The graphic at the top of this post is the cover of my syllabus for this course.  I have no affiliation with the course or Harvard Medical School, I just paid the fee to take the course like everybody else.  The graphic is included here is to provide information about the course that I reviewed in this post.

Personally Intervening in the Case of Public Intoxication

I am at the Fairmont Copley Plaza Hotel in Boston.  I made the trip for the Harvard Neuropsychiatry Course.  My wife and I decided to go out and look at some architecture and walked out the side entrance onto Dartmouth Street.  There on the sidewalk was a young woman who appeared to be doing a down dog.  The only problem is that she did not seem to be able to get out of it.  As she pushed herself up, it was apparent she was severely intoxicated.  She had drawn a small group of observers, people were staring at her and not doing much of anything.  Being strangers in town we decided to keep moving and let the locals handle it and headed down Dartmouth toward Boylston Street.  After about 100 yards the young woman got up and started walking down the sidewalk and at times staggering into the street.  Vehicles travelling at about 30-40 mph had to stop or take evasive action in order to avoid her.  She was not aware of the near misses and kept wandering farther out into traffic.  This was unfolding in full view of hundreds of people in Copley Square and three television camera trucks interviewing people about the election results.

At that point, I could not stand by to wait for her to get hit by a car.  I was in Philadelphia once back in 1975 on a packed sidewalk.  At the red light a guy next to me inexplicably stepped off the curb against the light and was hit by a speeding van.  I can still see his body arcing through the air and landing face down on the asphalt about 50 yards away. I don't want to see that again.  I walked up to the woman and physically guided her back onto the sidewalk and asked if I could call someone.  She was obviously intoxicated and her speech was 80% unintelligible.  She was able to tell me that she wanted to get on a subway train to a suburb.  There were two subway stations available and a passerby helped us out by telling us where we needed to take her.  I helped her across Dartmouth and at that point she became agitated and started to walk out into the street again.  I tried to guide her to a seat at a bus stop and she slumped against the edge of the bus shelter and it looked like she was going to fall asleep.  At that point, I asked my wife to call 911, because it was obvious that she could not safely travel on her own.

She became agitated and angry.  She demanded to know where I was taking her and bolted across the street to the the wrong subway station.  We had the 911 operator on the line and when we reported what happened, the operator said: "well she's on the subway - it's out of our hands now" and hung up!  We crossed the street and went underground looking for her.  I was concerned that she would fall off the subway platform.  She had negotiated the turnstiles and it was not obvious how that happened, but there were some embarrassed looks on the faces of the transit personnel.

I watched her get on the train.  One precarious short step forward, followed by a long lean backwards.  During the lean, all of the exiting passengers halted in their tracks as if they were waiting for her to fall over.  After a few seconds - she regained her balance and plummeted past them onto the train.  The train pulled out and she was gone....

We helped her as much as we could.  Two people assisted us, hundreds did not.  We avoided a catastrophe - at least in our immediate vicinity.  From the public official we called, that was apparently all that the citizenry of Boston expected.  I did not notice until later at night that there were a significant number of people with chronic mental illness around Copley Square.  Many of them were incoherent or shouting illogical statements in a loud and vaguely threatening manner.  Still - they were not wandering in traffic and appearing to be at high risk for a fatal encounter.  It is possible I guess that the threshold for intervention is altered in that context, but the young women in question was neatly dressed and obviously ataxic, dysarthric, and sedated at times. In that case, the many people who saw her decided to do nothing but watch.

I thought I would document this all here with a suggestion.  If you see a fellow citizen intoxicated and in danger, I recommend intervening in that situation.  I don't think that you want to be second guessing yourself if you elect to do nothing and witness a catastrophic event.  This is a clear example about why public intoxication is not a humorous event like it is typically portrayed in the movies. It is also an example of the limits of what can be done.  Of course you always have to use your judgment in these situations.  You  can't put yourself in danger.  Private citizens cannot take physical custody of another person.  I could only help this person as much as she would allow even though her judgment was clearly impaired.

Acute intoxication can easily be a life threatening experience.  The danger can be either the direct result of the intoxicant or the result of inadequate self care.  I have seen too many people killed outright or in a trauma or burn unit because of that lack of ability to take care of oneself.  Even an unsupervised fall at home can be fatal.

So - do what you can.......


George Dawson, MD, DFAPA      


Supplementary:

For some reason, I have had the opportunity to intervene in many of these incidents in the past varying from a retiree backpedaling out of a rural convenience store and slamming into me at 7AM in northern Wisconsin - to picking up someone off a hospital floor and getting him to the Emergency Department.  My wife was with me for the first incident and she was quite upset thinking that the old guy had a heart attack or a stroke.  I told her not to worry - he was drunk even though it was 7 AM and he had driven himself to the store across a busy highway.


Attribution:

Photo at the top is from Wikimedia Commons with the following references from that site: By User:Eos12 (Own work) [Public domain], via Wikimedia Commons https://commons.wikimedia.org/wiki/File%3ACopleySquare.jpg per the listed release into the public domain by the originator.




         

Foreign Policy Implications Of The Business Takeover Of Medicine

Don't worry.

This post is not about the current Presidential election.  I have no horse in the race.  Nobody to vote for.  I have been a staunch 3rd party voter for a long time and there is not even a third party candidate that I would currently vote for.  I know that opens me up to criticism from major party partisans who commonly accuse independents of either losing them the election or being too arrogant to hold their nose and vote like everybody else.  I trust my nose more that I trust that kind of rhetoric.  The current campaign highlighted everything that is wrong with the political process including a lack of focus on real issues, a lack of inspiring candidates,  and plenty of dishonesty on both sides.  I want to focus on one real issue and that is national security.  And I want to get at it from a perspective that is described primarily on this blog.

Early in the 21st century, I involved myself in a lot of political debates.  As an example, I was very active in the debates about whether the United States should have invaded Iraq under President George W. Bush.  At the time there was the unfounded belief that Iraq had weapons of mass destruction and a push to invade even though UN weapons inspectors under Hans Blix had really not found any positive evidence.  Minnesotans is a state with active political dialogues.  Senator Paul Wellstone and his fellow Democrat and current Governor Mark Dayton were two of the few Senators who voted against authorizing the use of force in Iraq and the rest is history.  Unnecessary wars, massive military spending, and an ongoing drone war carried on by the Obama administration.  The longest continuous period of warfare in the history of the USA.  The end result is that we are in a continuous war against terrorists,  continuous cyberwarfare against China and Russia, and we are current seeing significant military build ups by those same countries.  All of this against the backdrop of President Eisenhower's remarkable farewell address to the nation televised January 17, 1961.  The relevant sections include (my emphasis added):

"..........A vital element in keeping the peace is our military establishment. Our arms must be mighty, ready for instant action, so that no potential aggressor may be tempted to risk his own destruction.

Our military organization today bears little relation to that known by any of my predecessors in peacetime, or indeed by the fighting men of World War II or Korea.

Until the latest of our world conflicts, the United States had no armaments industry. American makers of plowshares could, with time and as required, make swords as well. But now we can no longer risk emergency improvisation of national defense; we have been compelled to create a permanent armaments industry of vast proportions. Added to this, three and a half million men and women are directly engaged in the defense establishment. We annually spend on military security more than the net income of all United States corporations.

This conjunction of an immense military establishment and a large arms industry is new in the American experience. The total influence -- economic, political, even spiritual -- is felt in every city, every State house, every office of the Federal government. We recognize the imperative need for this development. Yet we must not fail to comprehend its grave implications. Our toil, resources and livelihood are all involved; so is the very structure of our society.

In the councils of government, we must guard against the acquisition of unwarranted influence, whether sought or unsought, by the military industrial complex. The potential for the disastrous rise of misplaced power exists and will persist.

We must never let the weight of this combination endanger our liberties or democratic processes. We should take nothing for granted. Only an alert and knowledgeable citizenry can compel the proper meshing of the huge industrial and military machinery of defense with our peaceful methods and goals, so that security and liberty may prosper together........"      


Eisenhower was a genius -  decades ahead of the current thinking on conflict-of-interest and its problematic results.  Going beyond the famous reference to the military industrial complex, Eisenhower's speech was about balance, conservation, and mutual respect. Disarmament described as being necessary because another war could destroy civilization. It was a speech made by a military expert turned statesman - balanced and very reasonable.

But despite Eisenhower's best intention, the American military has marched on with three unnecessary wars in my lifetime and continued record amounts being spent on the machinery of war.  In 2105 the US spent $596 billion dollars - more than the next 7 nations combined.  The Department of Defense is the largest single employer in the world.  The defense budget has long been the subject of cost overruns and overspending.  The word corruption is rarely used appropriately in American politics, but what would Eisenhower call  a $640 toilet seat?  From that same timeline - cost overruns alone add an additional 25% to the cost of weapons systems.  It seems clear that top down management massive budgets in a political atmosphere dominated by funding concerns, lobbyists, and special rules that favor the major parties is a recipe for inefficiency at best and corruption at the worst.

Parallels between what happens to the military budget and healthcare funding are undeniable.  In health care - the politics is clearly on the side of large businesses that were put in place as proxies by the federal government for containing costs - despite the clear evidence that has not happened.  Professional organizations also lobby they are generally ignored relative to business interests.  Per capita health care spending in the US is roughly 40% more than the next highest nation with no incremental increase in quality and much worse access to health care.  All of this mismanagement flows from politicians and bureaucrats at federal and state levels who talk about the constant need to reform health care.  The only notable reforms have been the use of large health care companies as inefficient proxies for government control,  selective rationing of specific areas of health care like psychiatric and addiction services, ballooning administrative costs, and placing an intense, costly level of administrative control over the physicians who are delivering the service.  Instead of learning from the past 30 years, the managers at all levels are doubling down with more requirements and regulations.  We have an endless supply of $640 toilet seats in the health care system and at the same time entire states where a person cannot get adequate treatment for an addiction or a psychiatric problem.  The government and business side of the equation needs to cling to the myth that this type of management is necessary, despite the fact that it was unequivocally demonstrated in 1998 that it was not and the more important long term trend that these business managers add no value to the system as all - apart from what they can make up as advertisements.

Does that sound like a system that can manage foreign policy or military strategy?  Somewhere along the line Americans are led to believe that we have competent military leaders who are advising Congress and the Executive branch.  In order to accept that advice a lot of political demagoguery that occurred in the election campaigns must be set aside.  A lot of past mistakes must be acknowledged and corrected.  A lot of the accusations about immoral and criminal behavior do not inspire the confidence of Americans or other citizens around the world. The scare tactics about whose finger is a safer finger to put on the nuclear button needs to be stopped and a more sober discussion about stepping back from high alert nuclear status and disarmament needs to happen.  Warfare and aggression should never be the default position.

The major difference between the military and healthcare funding is that the financial drain on the averagae family for military funding is less transparent that healthcare.  With costs being transferred to the working class under high deductible plans, the average retired couple paying and average $250K in retirement for healthcare, and now exploding costs for Obamacare, working class families are tired of paying excessive amounts for healthcare.  Any head of household who has survived the tech bubble stock market crash, the housing bubble crash, and the associated Wall Street scandal where hardly anyone was prosecuted and all of the major players were essentially unfazed.  Everybody knows some working class person who ended up fined or sent to jail for cheating the IRS.  It is also common knowledge that these infractions are trivial compared with tax breaks and questionable financing by the affluent.

Although the major parties have certainly played a role in orchestrating this dramatic fiasco - they don't bear complete responsibility.  At many levels American culture is poorly equipped to deal with tough problems.  There is a love of technology but a focus on impoverished data sets.  There is a limited understanding of current problems and potential solutions.  The best solutions are rarely reached by political compromise and the end to those arguments typically results in wrapping oneself in the flag and declaring that there has never been a better system (or country) invented.

Rather than putting it all behind us and uniting behind the next President like we all traditionally do - I hope this ugly campaign gets Americans contemplating the larger issues instead of what is commonly referred to as "the narrative".  We need to get back to the real story itself rather than the narrative.  The issues are there and they are not going away just because some politician is trying to buy your vote with money, a job, an empty promise, or special interest politics.  The issues are there no matter how we get "handled" by the managerial classes.

That is what we all have to keep in focus.



George Dawson, MD, DFAPA  


Supplementary 1:

I filed the above piece on Election Day, at least 8 hours before the New York Times election site started to predict that Donald Trump had a "greater than 95% chance" of winning the Presidential Election.  Since then I have been shocked at the number or reasonable people who are outraged by the election result and suggesting that this election is an indictment of the American character.  I won't list the specifics but they are easily viewed elsewhere.  Maybe I am just a hardened Minnesotan who can still clearly remember when professional wrestler named Jesse Ventura shocked the major parties in the state by being elected Governor.  Looking at the debates he had with those candidates - the outcome should have been predicted.  Both the Democrat and the Republican in that race found themselves agreeing Ventura on most of the major topics.  As I drove into work the next day, I listened to a major party legislator predict a catastrophe due to a professional wrestler rather than a career politician.  And guess what?  No catastrophe - in fact - a seamless transition.  The Governor's Office ran well.  Ventura's  only error (and it was a big one) was not to make the most of this victory and prove once and for all that the major parties can be superfluous in the process.

The failure of the polls to predict the election result, is instructive for any students of sampling and statistics.  If the sample is inadequate, don't print the headlines based on the inadequate sample.  I don't think the second question about that has been answered yet.  That question would be whether enough people are "off the grid" or uncooperative with the sampling process enough to make these polls predictably unpredictable.  Is it safe to say it was a failure of Big Data?

From what I know about the political process I see this playing out a few ways:

1.  Trump makes a seamless transition to office in a manner very similar to Ventura.  It will actually be easier for a Trump transition because he is technically a Republican,  even though many Republicans clearly dislike him.  Ventura was a member of the Independence Party and both parties disliked him and yet he was able to form a reasonable cabinet and nobody noticed that there was not a Democrat or a Republican in office.  He maintained a populist position by provided tax rebates.  The real potential for damage from a Trump administration will be a ballooning federal deficit, but even then it is a matter of degree.  There is no way that any Democrat or Republican will establish a precedent of actually paying for the expenditures on their watch.

2.  I have been stunned by the naivete that some people have about how men talk.  Trump's 'locker room" talk is what I am referring to.  I had a discussion last week about this very issue.  One opinion was that this kind of talk was a "generational thing" - in other words done only by dinosaurs like me.  I have certainly talked with men of all ages who refer to women in a crude manner.  I certainly don't use those terms myself and never have.  I don't "approve" of these references, but I also realize that men who talk that way are certainly not waiting on my approval.  I know this type of discussion exists.  I also know the meta-language involved.  In other words, the language has different meanings in different contexts like most language does.  I will let the linguists come up with a detailed analysis, but at the common sense level it is clear that a lot of people could ignore it.

3.  Trump has been conciliatory in his early remarks since the win.  The key question at this point is whether he can maintain that demeanor.  If he does not become antagonistic and uncompromising he has a great opportunity to seen what he can accomplish. From the political debates, it was clear that the Trump campaign was more about process and rhetoric that it was about content and a mastery of the issues.  He needs to take a lesson from Governor Ventura about what not to do when you unexpectedly get into office.

4.  Most but not all of the pundits seem to have missed the point that a lot of the Trump emotionality was directed at the working class and the working class has not fared well in American politics for decades.  Wages are flat, unions have disappeared, health care costs have increased and were set to explode with Obamacare.  Against that backdrop, the major parties have really done nothing but shore up Wall Street.  The working class has been a traditional mainstay of the Democrats.  As my grandmother used to say" "They are for the little guy!"  That has not seemed to be the case to me for a long time.

5.  Most Trump supporters do not take him literally - this is my speculation and it is in direct opposition to opposition to other more radical theories of the motivations of Trump supporters.

Just a few early observations about why a Trump presidency is not necessarily a catastrophe and also - how it happened.....        



        

Remind Me Why Managed Care Companies Don't Offer Computerized Psychotherapy?

One of my mentors in residency enlightened me to the advantages of computerized psychotherapy.  That was in the days of the IBM AT PC or about 35 years ago.  I had an updated conversation with him about this 4 years ago after he gave a presentation that examined the more recent literature.  That literature had not only taken off, but there were more widespread applications.  Many of those applications were on a large scale using standard psychotherapeutic approaches.  Some of the research addressed the issue of patient acceptance and found that it was generally acceptable and more convenient for patients.

Interestingly, these innovations in computerized psychotherapy occur at a time when healthcare companies in the USA are implementing psychopharmacology on a large scale with minimal input from psychiatrists.  The collaborative care model for depression consists of patient in primary care settings rating depression with a standardized rating scale and generally being put on an antidepressant.  There is much wrong with this model, not the least of which is the fact that a rating scale is not a diagnosis and it probably leads to broader exposure to antidepressants medications.  It is nonetheless heavily promoted as an acceptable approach to the treatment of depression.

In the meantime, large organizations like the National Health Service in the United Kingdom have computerized psychotherapy services for the treatment of depression, generalized anxiety, and panic disorder.  The evidence base for these services is provided by the National Institute and Care Excellence (NICE).  According to the NICE guidelines for depression, computerized cognitive behavioral therapy is recommended as  "step 2 services for people with subthreshold, mild and moderate common mental health disorders".  In the US there are no similar resources and the treatment of depression as identified by screening techniques resembles a model of active monitoring and pharmacology with the widespread use of antidepressants.  Psychotherapy within health care systems in the US is sporadic and when it does occur seems to be based on a model of crisis counseling rather than any research model of the psychotherapeutic treatment of a specific disorder.  A main driver of that delivery system is the very low expense of modern generic antidepressants.  Some of these medications coast as little as $4/ month and are available at another discount if 90 day supplies are ordered.

A recent review of NSDUH data looked at medication utilization for the treatment of mental illnesses and found that the overall prescription rates had increased substantially across different generations of outpatients.  According to the authors there was a increase in prescription of psychiatric medications for all adults of about 28% between 2008 and 2013.  Of course the bulk of that medication is not prescribed by psychiatrists.  That paper also referenced a meta-analysis of patient preference for psychotherapy (2).  That study has significant methodological limitations and typical clinical constraints are probably not well represented.  In clinical practice, severely ill patients with psychiatric disorders or addictions are typically seen in intensive setting where psychotherapy is available and in many cases necessary like DBT or GPM.  The patient's I see list lack of rapport with the therapist, lack of direction in therapy, excessive self disclosure on the part of the therapist, cost, and inconvenience as being the main limiting factors for psychotherapy.  Most if not all of these constraints disappear with a computerized approach.

That brings me to a good example that I mentioned in a recent post on mindfulness based approaches to psychotherapy (3).  In the article I referenced, the Headspace web site was mentioned as a mindfulness based approach to psychotherapy.  The site offers 10 - 10 minute sessions and a more extensive selection of sessions at a reasonable cost after that.  As I completed the first 10 sessions, the advantages were immediately obvious.  The therapy model is obvious and there are standardized metaphors as examples.  The therapy is consistently delivered in the comfort of your own home and on your own schedule.  The site can be used by any psychiatrist or psychotherapist to augment outpatient treatment.  The site is valuable to trainees who are attempting to learn and deliver these mindfulness interventions on their own.  The site is cost effective - you can keep repeating the initial 10 sessions for free as much as you want or purchase additional sessions with different content.  A lifetime subscription to the web site is available for what might be the out-of-pocket cost of two psychoanalytic/psychodynamic sessions.

Every time I have been on the web site there are about 40,000 users logged in to the site.

Every managed care and health care company has a massive investment in IT to support their electronic health record and other clinic services.  Offering computerized psychotherapy would be a minor addition to those services.

Remind me again why managed care companies are not offering this option for depression, anxiety, and insomnia?    

And remind me why this is not the first step before prescription medication, especially in primary care settings?



George Dawson, MD, DFAPA



References:

1:  Han B, Compton WM, Mojtabai R, Colpe L, Hughes A. Trends in Receipt of Mental Health Treatments Among Adults in the United States, 2008-2013. J Clin Psychiatry. 2016 Oct;77(10):1365-1371. doi: 10.4088/JCP.15m09982. PubMed PMID: 27486895.

2: McHugh RK, Whitton SW, Peckham AD, Welge JA, Otto MW. Patient preference for psychological vs pharmacologic treatment of psychiatric disorders: a meta-analytic review. J Clin Psychiatry. 2013 Jun;74(6):595-602. doi: 10.4088/JCP.12r07757. Review. PubMed PMID: 23842011; PubMed Central PMCID: PMC4156137.

3:  Smallwood J, Mrazek MD, Schooler JW. Medicine for the wandering mind: mindwandering in medical practice. Med Educ. 2011 Nov;45(11):1072-80. doi:
10.1111/j.1365-2923.2011.04074.x. PubMed PMID: 21988623. http://onlinelibrary.wiley.com/doi/10.1111/j.1365-2923.2011.04074.x/full

Within the body of that article the web site called Headspace ( https://www.headspace.com/ ) for mindfulness training is referenced.

Disclosure:

I have no conflict-of-interest in mentioning the Headspace site.  I am not endorsing it and they do not endorse me.  I have no financial interest in the site.  I am listing it here as a resource for mindfulness based approaches because I think it is useful and it was recommended in the literature by a psychologist who I consider to be an expert in this field.

Addictions Neuroclinical Assessment

I was quite excited when I heard about this paper in Biological Psychiatry a few days ago.  It was hyped as a way to forgo the usual DSM approach and others and make an addiction assessment based more on the neuroscience of addiction.  The basic dimensions for assessment are highlighted in the above diagram.  The authors make a compelling argument in terms of what is needed in addition to the clinical criteria "that has provided a reliable foundation for the practice of addiction medicine."  The clinical criteria that they are referring to are DSM criteria or basically problems and symptoms that are used to classify disorders from non-addictive use of the same substances.  Even the most biologically based of these symptoms - craving, tolerance, and withdrawal vary widely across all individuals in the same diagnostic group.  That variation is most likely due to biological complexity.  The authors contend that there should be a way to examine that heterogeneity among the larger clinical divisions to get at pathophysiologically based subtypes.  They suggest that the focus should be more on process than outcomes.  

They use cancer as an example of the importance of specific etiology in the diagnosis and treatment of disease.  In the case of the diagnosis and treatment of breast cancer, the BRCA1 gene is used to predict increased risk for breast cancer for a subpopulation of women with this diagnosis.  Detection of HER2 protein overexpression can predict response to a monoclonal antibody  (trastuzumab) that  interferes with the HER2/neu receptor.  All of this information is used within the existing clinical context and even then addition information about breast cancer would probably be useful.  The review several similar initiatives in psychiatry and addiction and compares the ANA (Addictions Neuroclinical Assessment).   The other examples include the Research Domain Criteria (RDoC), the Cognitive Neuroscience Treatment Research to Improve Cognition in Schizophrenia (CNTRICS), and the Impaired Response Inhibition and Salience Attribution (iRISA).  Clinicians will note that none of these initiatives has gained a foothold in routine clinical practice.  Only the CNTRICS has assessments across all 5 of the domains addressed by the ANA.

Looking at the major domain for assessment, the authors provide definitions and the rationale for their inclusion.  They define executive function as "processes related to organizing behavior toward future goals".  The reality is that executive function is really defined by convention, typically measures that are thought to reflect to reflect frontal lobe function like mental flexibility and set shifting.  Addiction significantly limits the repertoire of these frontal mechanisms to maintain rather than critically assess the addiction.  Impaired glutamatergic signalling to the stratum and extended amygdala and loss of top-down control are listed as the putative neuroscientific mechanisms.  Incentive salience is described as "psychological processes that transform the perception of stimuli, imbuing them with salience and making them attractive."  The underlying mechanism is given as "activation of mesocortical dopamine system".  Familiarity with the reward and motivational system that is focused on the ventral tegmental area and its dopaminergic projections to the nucleus accumbens is at the heart of this system but it alson includes projections to the frontal cortex.  During the initial phases of exposure to rewarding stimuli, the dopaminergic neurons will fire.  As that process continues, anticipation of reward causes them to fire.  That phasic dopaminergic activation leads to altered response to cue and noncue targets, craving, and heightened relapse risk.  Negative emotionality is defined dysphoria and negative emotional responses to stimuli associated with addictive states.  These states are often mistaken for an treated as depression.  The ANA has instruments to assess hypohedonia.  Brain stress and antistress systems are thought ot be involved with the latter contributing to negative emotionality.

When I look at the table of measures that comprise the ANA a couple of scenarios come to mind.  The first is the omnipresent Attention Deficit-Hyperactivity Disorder (ADHD) diagnosis encountered in psychiatric practice.  Most of these diagnoses are not made by psychiatrists.  In the people who I reassess because they may have an addiction, when I ask them about the diagnosis, I am likely to hear: "My primary care doctor sent me to a psychologist and I had two hours of paper and pencil and computer testing."  The problem is that there are no neuropsychological tests for ADHD, no matter how extensive.  Most of the test battery would be for executive function - right out of the ANA and those tests are not necessary for the diagnosis.  That led Barkley to come up with his own version of checklist symptoms that he thought matched the executive function deficits of the disorder better than the neuropsychological tests did.  The second diagnosis is Alzheimer's dementia.  Cortical dementias are based on higher cortical deficits, memory problems and the characteristic progression.  An extensive test battery for the disorder is not indicated.  I would argue that medical testing to rule out other causes is the single most important biomedical approach and that an extensive test battery would not add much.

In summary, there are several questions about the ANA.  The first is whether it can ever be widely implemented in its current form.  The total length of the test is 205 minutes on paper and three of the tests are based on neuroimaging.  The authors estimate that it would take about 10 hours to complete and cost anywhere from $3000 to $5000 per individual.  That alone restricts the ANA to urban areas where psychiatric clinics are well staffed and have access to neuroimaging and staff with the time and interest in complex diagnoses.  That runs counter to a 30 year trend to ration detox and addiction services and largely move them off of medical campuses.  It also runs counter to the collaborative care idea that suggests psychiatric staff can be marginally involved in primary care clinics that equate psychiatric diagnosis and treatment to a metric that can be completed in 5 minutes or less.  Following that logic, the ANA might fly in these settings if it was 5 to 10 minutes long and would reliably lead to a prescription.  A managed care organization (and they all are these days) will not be applying this kind of test to people with addictions.  It is hard to determine how many people with addictions are seen and assessed by these organizations.  The second question involves the cost-effectiveness argument applied to medicine.  I am certainly averse to this argument, but all of the bean-counters seeing this will ask: "If we do all of these tests will it change anything?  Current treatment of addiction is a crude proposition, but are there specific treatments based on the testing that will improve the process and outcomes of treatment?

From the pure egghead side of the equation, does the ANA go far enough in exploring the conscious state of the person with addiction?  I find that very few assessments examine the cycle of euphoria and positive reinforcement and dysphoria and negative reinforcement best described in a statement by one of the coauthors of this paper:

"Addiction is a chronic relapsing syndrome that moves from an impulse control disorder involving positive reinforcement to a compulsive disorder involving negative reinforcement." - George Koob

As far as I know there are no more accurate statements about addiction that capture course, clinical phenomenology, and implicit neuroscience in one sentence.  If that sentence was all that you knew about addiction, you could diagnose and treat most disorders by deriving your clinical interview from these first principles.  The problem in the DSM world is that the interview ends up being a collection of impersonal markers that may of may not uniquely apply to the person being assessed.  The ANA seems to take the encyclopedic approach to this problem.  The intense euphoric state of early addiction is rarely explored.  A lot of what constitutes a clinical evaluation is the tabulation of various adverse outcomes rather than the ongoing process.

Just adhering to the basic science of the situation are there easier and more straightforward approaches to executive function, negative emotionality, and incentive salience.  I think that there might be.  I am  familiar with most of the measures suggested by the authors but the proper analysis requires a much closer look at all of the suggested metrics and how well they will discriminate between thousands of people with the same clinical diagnosis.  Although I dislike using it in the same context, the PHQ-9 is a good example of a purported measure of depression that really does not discriminate and the authors include several similar measures in their list including the Beck Depression Inventory, the Beck Anxiety Inventory, the Fawcett-Clark Pleasure Scale, and the Toronto Alexithymia Scale.  Degrees of freedom are important in thinking about the total number of items available to characterize the population versus large binary discrimination.  A lot of these measures don't seem up to the task, but i am the first to admit that it would be useful to see research that focuses on that issue.

In the meantime, the take home message for any interested clinician is that the ANA is not ready for prime time - for a number of reasons - but stay tuned.   There also seems to be an opportunity to come up with new assessments of the systems in question that are more efficient and a better complement to clinical practice.

  

George Dawson, MD, DFAPA

References:

1: Kwako LE, Momenan R, Litten RZ, Koob GF, Goldman D. Addictions NeuroclinicalAssessment: A Neuroscience-Based Framework for Addictive Disorders. Biol Psychiatry. 2016 Aug 1;80(3):179-89. doi: 10.1016/j.biopsych.2015.10.024. Review. PubMed PMID: 26772405; PubMed Central PMCID: PMC4870153.

Managed Care Reform - The 4" x 6" Card

I got carried away in the last post and added this as supplementary information.  Sometimes I forget that this is a blog and not a research paper in Nature.  So here is the suggested 4" x 6" note card that is all that is required to reform an out-of-control managed care industry.  It is more out of control with regard to psychiatric and mental health services than any other health care services and some of the reasons were given in my previous post.  The additional data is contained in this blog and the obvious places to look have to do with jails being the largest providers of mental health services,  per capita psychiatric beds being at lower numbers than most OECD countries, overcrowded emergency departments due to the lack of available psychiatric beds and less intense psychiatric facilities, the lack of psychotherapy services. the lack of state-of-the-art psychiatric evaluation facilities, the lack of structured facilities for children with psychiatric problems, a lack of detox facilities, and a serious lack of treatment facilities for substance use disorders.

In one way or another - all of these services are casualties of managed care.

The 4" x 6" card is all that is needed to regain a focus on quality care and starting to develop adequate services again.  As we have recently seen - 300 page rewrites of health care law that are unreadable and contain a line for every business Congress wants to fund accomplish nothing.   Print off the card and spread the word.

Anything short of these basics is just special interest politics as usual.  In politics the excess usually means coming up short.


George Dawson, MD, DFAPA

Another Bad Editorial Decision and more.....

I am on record recently pointing out how top medical journals have evolved to the point that they are posting a continuous stream of opinion pieces of variable quality.  It is not uncommon to find that from week to week diametrically opposed views on topics are published.  The most alarming trend in the posting of business views; usually along the lines that there needs to be continuous business reform in health care.  These are basically opinion pieces looking for a political foothold.  The precedent of course is managed care.  After it gained a political foot hold in the Clinton administration it became a business worth hundreds of billions of dollars.

In the case of managed care it was sold as widespread "reform".  After 30 years of managed care rationing the per capita health care costs in the USA are quite unbelievable when compared with even the next most expensive system ($9,086 in USA versus $6,325 in Switzerland).  The other top ten nations are seriously outdistanced.  Rather than acknowledge managed care as just another political flop there are endless editorials on how it really slows the growth of health care.  There are editorials of how it is really a success despite these outrageous numbers and nearly complete hegemony by managed care and insurance companies.  It is difficult to see how responsible editors of medical journals can continue to publish this pro-business propaganda.  They are certainly more circumspect about making these pages a sounding board for the pharmaceutical industry.

The largest divergence when it comes to health care costs is a managed care propensity for a disproportionate focus on mental health and psychiatric services.  This is nothing new.  It has been well documented since the  Hay Group found that from 1988 to 1997 that a total value of health care benefits for over 1,000 large U.S. employers declined by 10%.  Of the decline general health care benefits declined by 7%, but behavioral health benefits declined by 54%.  Behavioral health is managed care speak for mental health and psychiatric services.  Those same services dropped from 6% to 3% as a total percentage of health care costs.  While general medical services increased by 27% outpatient mental health services dropped by 25%.  Mental health benefits from employer based health insurance dropped by 50% between 1988 and 1998.  The true costs of managed care rationing have never been seriously examined.  There is an obvious conflict of interest when the government basically invents and industry based on a flawed political theory and the system floats based on these invented special interests.  

I did not really think that these opinion pages could be any worse until I happened to open up JAMA Psychiatry the other to do some reading while I ate my Wheaties.  I ran across an article called "What to do when your managed care firm says no."

The answer from my experience is nothing - you are basically out of luck.  In my experience managed care companies don't care if you live or die.  They don't care if you have the world's worst eating disorder.  They don't care if you have tried to kill yourself while intoxicated and your psychiatrist is saying that you will absolutely use alcohol, heroin, methamphetamine, dextromethorphan or any number of drugs immediately if you are not sent to treatment after acute stabilization.  They don't care if you need a longer period of time in the hospital.  They don't care if you have been committed for a suicide or homicide attempt.  I am not saying all of this just because it is true.  I am saying it to point out something that is often overlooked.  Why would a managed care company or MCO care?  They have never met you and have no personal responsibility to you.  As a business, especially in the new era of business management - they basically have a responsibility to make money for their shareholders.  The caring aspect of MCOs is really a public relations stunt.  They involve your doctor and make it seem like their decision - is your doctor's decision.   They waste your doctors time in order to make it seem like their refusal to pay for your care is somehow a conjoint decision with your doctor.

But back to the article.  Here we have a managed care insider giving advice to patients and physicians on how to deal with their denials.  I would consider this all tongue in cheek advice if it was not sitting right there in JAMA Psychiatry.  I will focus on a most familiar scenario denial of inpatient care.  This is a case of a hospitalization for schizophrenia where "the hospital tells the mother that it is time to discharge her son because the MBHO (Managed Behavioral Health Organization) says so and has an appointment for her son to be seen a month after discharge" (p. 1109).  The author suggests that in the case of this dispute the vendor will have a formal appeals process and that will include "a review by a psychiatrist not on the MBHO's payroll."  That has not been my experience.  The review is generally done by psychiatrists a long distance away.  They may not be licensed in the state where the patient is hospitalized.  The ones I have talked with are either openly hostile, pretending to be on your side, or clueless about the severity of inpatient problems.  Keep in mind that most psychiatrists do not practice in inpatient settings beyond their training years.  I have never seen a study that looked at whether these reviewers were actually treating very ill psychiatric inpatients - but from my conversations I think they were not.

The author goes on to say that the family can then apply to the employers benefits manager to apply leverage to the MBHO and have leverage in the case of inadequate care.  What is wrong with that picture?  For starters any sequence of events where clinical decisions are being made by business types is by definition - inadequate care.  Secondly, there is an inherent conflict of interest when your employer and an insurance company they are contracting with start negotiating your medical or psychiatric care.  Once again - neither of them has a responsibility to you for giving you the best possible medical advice.  They are giving you a business decision that saves them both money and calling it a medical decision.  The MBHO is protected against liability from that decision by federal law.  Your employer is protected by saying it was the decision of the MBHO and not them.  If you really think that your employer is interested in your personal health, go talk to the decision maker in person and note their level of interest.

The final vignette provided by the author is there to justify managed care.  It has been their war cry since day one and that is excessive utilization.  In this case we are lucky to have Big Brother watching in the case of psychotherapy delivered so inexpertly that the therapist states: "I am this patient's only friend so she needs to to keep seeing me."  This was after years of treatment.  I think that we can  all breathe a sigh of relief that an MBHO being paid millions plus incentives to ration psychiatric care can identify the worst therapist in the USA after years of therapy.  It is a miracle of modern management.

When you have editors who accept this level of an article it is a direct insult to anyone who has personally dealt with these companies and who knows what is going on.  It is a direct insult to the medical profession and physicians who have dedicated their lives to learning complex, highly technical profession to suggest that they should be clerical workers and work for free as employees of managed care companies.  It is an insult to desperate patients and their families who put up with all of paperwork, inefficient billing and arbitrary denials of care.

If the editors of medical journals are not bright enough to question the accuracy of a piece like this or they have not had the clinical experience of dealing with the constant harassment of managed care companies - they should defer the commentary section to somebody who knows what they are talking about.

Better yet - time for a moratorium on business and political commentary in medical journals.  When you try to complete with blogs - keep in mind that you are competing with a low standard.  That turns out to be no competition at all.  


George Dawson, MD, DFAPA

Reference:

1: Essock SM. What to Do When the Managed Care Firm Says No.  JAMA Psychiatry. 2016 Sep 28. doi: 10.1001/jamapsychiatry.2016.2409. [Epub ahead of print] PubMed PMID: 27680607.

Supplemental -  The 4 x 6 Card on Real Health Care Reform

No room for this in the original above.  The solutions to businesses and business managers making medical decisions about your health care is like most political quagmires in this country - very simple.  You can fit it on a 4 x 6 inch index card.

It goes like this:

1:   All managed care (MCO, MBHO) decisions are between the patient and the company.  The doctor is out of the loop.  The doctor advises the patient, the company says yes or no on the payment.  The doctor may have an alternative or the doctor may not.

2:  The doctor does no appeals , paperwork, reviews with the MCO.  Why would he/her?  The doctor does not work for the MCO and does not get paid for all of the time it takes to engage in what are business processes.  The doctor should not care what anything costs the MCO.  They have a tower of MBAs with nothing else to do but figure that out.

3:  The same process is true for PBMs (pharmacy benefit manager) - the pharmacy equivalent of MCOs.  The doctor does not work for the PBM and does not get paid for all of the extra time each day to essentially justify their decisions.  PBMs have another tower of MBAs with nothing else to do but price drugs to their advantage. 

4:  The MCO is liable for damages related to any of their financing decisions that result in harm to the patient.  No federal exceptions.

5:  Each state has an independent arbitration board comprised of physicians who are actively practicing in the discipline where the decision is being appealed.  The physicians are all actively screened for conflict of interest like the Medicare Peer Review Organizations that found there was no excessive use of mental health services or anything else in about 1998.  The arbitration board should contain only physicians - no insurance company insiders dedicated to shield the managed care industry.  Direct appeals by the public should be encouraged with the same amount of vigor that the public is actively solicited to complain against their physicians.   

Steps 1-5 above would assure physician recommendations in the best interest of you the patient rather than the financial interest of the managed care organization.  Unfortunately with Managed Care 3.0,  the rationing in many cases has been internalized.  Today physicians can be in a clinic or hospital setting that has internal case managers telling them what to do.  When managed care companies rationed some places out of business they were very successful in acquiring medical groups and facilities.  In other words; the doctors, the hospitals, the clinics and the pharmacies are all owned and run by the managed care company or a shell company.  They all get their marching orders from people in the management class pretending to be medical experts.

That should be a major problem - but in the manner of Orwell - if you use the term health care reform a thousand times - most people believe it happened.