Formerly The Status of Mental Health and Health Insurance: Years of Personal and Governmental Investment Down the Drain and Poorer Health in the Process
Observations of a Family Physician with Examples from My Patients
My name is Robert C. Bowman, M.D. I am a family physician and an advocate for underserved and rural communities. I practice half time at the University of Nebraska Medical Center Family Practice Clinic. The clinic serves about 60% Medicaid, but there are employees and also medical people. I have been there for over 12 years. I have had a chance to see the ebb and flow of situations in some of my patients for many years, particularly the impacts of the tar pit we call poverty and how we actually tend to prevent people from escape from this situation. These are true stories from our clinic. The names have been changed:
Chronic Illness: Welfare vs No Health Care - Evelyn and Greg had three children who were all doing well. Greg had a good job and Evelyn was an assistant manager for a chain store making $40,000 a year. Cutbacks cost her job and she took a lesser paying job. Her youngest son began to have stomach pains. She knew something had to be really wrong. Her persistence revealed sickle cell in her son and eventually the failure of his sickle cell birth testing as well as erroneous sickle test results on her husband. To attempt to keep him as healthy as possible, she does not keep him in a day care setting where he would risk more exposures to diseases. Of course this is more expensive but this is small potatoes compared to all of the medicines and emergency visits that her son needs. She holds on to her job and some hope for help even though finances look worse each month and her job security looks worse. The only thing that separates her in near poverty from the moderate wealth that she and her family could have, as well as the college education that she desires for her sons is sickle cell in her youngest child. A divorce and placement on welfare would be one alternative that might actually improve overall finances. This is, of course, a sad consideration and a really bad incentive in our current policy.
Helen and Larry return to poverty – When I first met Helen and Larry, they were doing pretty well. They had two cars and were about to put money down on a house. Helen was working at a local grocery store. A big strapping country girl, she prided herself on being able to life and move as much as any man. Many of the employees took advantage of this and asked her to help, which she was only happy to do. She suffered a back injury at work and had a prolonged recovery period. She settled into a deep depression. While she was away from work, her previous reputation as a good worker has been re-interpreted. The worker’s compensation insurance failed to provide assistance for her rehabilitation and then kept helping her at all. The company doctor did a 6 minute evaluation and a 6 page detailed report that did not reflect the patient's condition or exam. This was passed on to another consultant, biasing the next consultant with less than full information. Meanwhile Helen and Larry struggled. Eventually she recovered enough to resume some work, but was out 2 years of wages. Instead of workers comp paying the bill. Medicaid had to pay. Medicaid also had to pay for the delivery of her child. When her workers compensation case came to trial, she was advised by her lawyer to take the $3000 offered the day before trial. Desperate for money and deeply dependent on her parents, she did so. End result, minus Helen and Larry deep in debt and back where they were 5 years ago, the state out over $20,000 in Medicaid charges that should have been provided by workers compensation and health insurance. Helen and Larry’s family lost out on several thousand that they can ill afford. Now a few years later, Helen won her disability and got her wages. The judge rejected the worthless workers compensation evaluations for real medical care. However government will pay instead of business and insurance on this one. Helen and Larry lost 8 years of progress and are out of severe poverty now, but dependent on fixed income.
Marlene's endless cycles - Marlene first came to Nebraska from Arizona. It is likely that she was escaping legal or criminal issues. She entered a half way house in Omaha and worked her way out of drugs and depression, with the help of housing, Medicaid, and state support. Her son, age 6 at the time, had no respect for her and was out of control. His asthma was severe, requiring many ER and clinic visits and a few hospitalizations. As she improved and their living conditions improved, his asthma improved. Having seen what he was like before, it brought tears to my eyes to see him respect his mother again at a clinic visit. Depression and drugs returned again, and then another recovery. This time the recovery was prolonged by the onset of breast cancer. Again with the help of Medicaid and state assistance, she was able to do well. She returned to the work force and found a series of employers who were fairly flexible, so that she could meet her needs for treatment and her son’s need for assistance with asthma and school problems. For some reason, the state tired of supporting her. She was not able to get health insurance due to pre-existing conditions. She could not even consider paying $500 or more for continued health insurance. Other patients laid off have quoted $800 a month figures to continue coverage. Few even attempt to do this. For Marlene this was not a consideration as she had no income, rising bills, eviction notices, and utility cutoffs. One previous time the utilities were cut off, she was immobilized with depression, and the state took her children for a time, adding to her stress and depression. Recently the family disappeared from my care. I thought that they had gone to another state as per my last conversation, but in the past week I have heard from them again. Now they depend on the Salvation Army. Basically she is back where she was 5 years ago, except that her son is more bitter and they are both in worse health. The status of her breast cancer is unknown, but her prognosis without continued care is bad. With little support, it is actually worse. If she does deteriorate and die, she has no real family to care for her 2 kids. Now that she is off Medicaid, our clinic is still caring for her, but mostly by phone and by medication samples. Her risk of suicide is very high except that her mother checked out that way and she does not want to do that to her kids. Her son has significant risks from asthma, particularly since they have little control over his housing environment.
Update: Now she is going to school and is back on Medicaid. She had to do it to get care for herself and her son, who is again on maximum asthma meds and still having problems. She also has a caseworker who seems to care about her now.
Stephanie Had It Made – When I first saw Stephanie she was a mess. She had problems with her esophagus and skin and arthritis. She had severe allergies and sinus problems. Eventually she was diagnosed with multiple chemical sensitivity syndrome. Having a good educational background and some experience in a grocery store, she was able to move up to an accounting and then assistant manager position. This allowed her body to heal up but increased her stress levels. She eventually moved back to the accounting position. A string of illnesses and surgeries on her knees and back depleted her sick leave, but did not constitute enough of a problem give her disability income. Her boss, fearful of her falling at work, asked her to stay home a little longer. Her savings depleted, she turned to family assistance but there is little there. She stood in line for 3 hours to get $10 in food stamps. Her boss called around and found $35 dollars worth of food at a church. She gets regular calls from creditors and notices from utility and eviction notices. Next week she will have to risk a return to work on crutches. She depends on samples at our clinic for 5 major medicines, but suffers when she runs short. If she can avoid a fall and continue to repair, she will be able to restore her finances and her health. One slip and she is in total poverty and homelessness, despite her education, training, and experience. She is actually worse off than she was 5 years ago.
Ellen's Health on Hold - Ellen has been a caregiver for others most of her life. She cared for her husband in his final days before cancer took him. Ellen's car has been hit from behind on multiple occasions. She has had injuries involving 2 auto insurance companies and workers compensation. She has constant pain in her foot, knee, hip, and back. It is nearly impossible to tell where one injury starts and another leaves off. She is allergic to just about every medicine. Her husband died a few years back. She cared for an elderly lady for some time, until this lady became too ill to care for at home. Now Ellen scrambles to keep her home in repair and meet monthly bills. She needs care in other areas but cannot afford it. There is little hope of resolving her insurance claims. Fortunately two insurance companies were involved so they seem content to wait and pay some doctor’s visits and not much else. More extensive health care is out of her reach. Perhaps the insurance companies are waiting for her to die so that their responsibility will end. Her situation has not improved in 5 years and she may no longer be able to work. Her house is falling apart. Eventually she lost a lawsuit charging her lawyer with negligence, however others may succeed in these lawsuits where she failed since there are other cases pending.
Mollie's Child Repeats Her Life - Mollie has been close to death from depression and drugs on many occasions. She managed to recover and seeks care regularly. Painfully her teen daughters have chosen a similar path. She has continued to get them care, even across many miles in state institutions. Since she cannot afford private placements, she is dependent on the state for mental health. Since Nebraska is near last in the nation in mental health resources, especially for drug and alcohol problems, she has few options. Recently her child returned home from a facility. Initially she was doing well, but recently has come under the influence of an older teen and it appears that she is falling into old habits. In her last visit, it seems that she is attempting to get pregnant so that she can a) get independence from her mom and b) stop taking her psych medicines. In this instance Medicaid and state support are a weapon she is using so that she does not have to be accountable to her mom or the state. Mollie struggles against recurrent depression herself. Her situation is worse now than 5 years ago. Better health and mental health care would help her and her daughters. Her most recent visits have been to the ER for chest pain, likely all stress reactions.
Erin's Lawyers Can't Help - The next patient I will call Erin because she reminds me of Erin Brockovich. Like the movie and real life Erin, she also works for lawyers. She suffered a rollover auto injury and has constant neck and arm pain. Like Erin, she was not able to get help from the auto insurance people. They refuse to pay for her medicines or treatments. This is sad considering that she works for lawyers. Like Erin, she has kids to care for and a job and it is difficult for her to get care or pay for medications. She also depends on samples when we have them. She is much worse off in the past 3 years and could well be unemployed soon if her condition worsens. Given her occasional outbursts at the clinic, I wonder about her other situations. Chronic pain and hopelessness takes a toll. .
Michelle Gets Tossed - In a recent federal push to remove people from disability rolls, Michelle's disability status for depression, anxiety, arthritis, and other conditions was removed. She spend 18 months scraping by with the help of family and friends and finally found a lawyer to help. She easily qualified and was returned to disabled status. She tries to pay people back but this is difficult on her fixed income. End result is that she is deeper in debt, that much closer to loosing housing, and her family and friends are poorer for helping her. We were out a few visits and a lot of samples. Given her situation, she probably would not have come except she needs the samples and she trusts me. She still rarely goes outside the home but we don't even talk about extra mental and physical therapy that will help her. Maybe this month she will agree to re-start the long and painful process back to being in contact with others. Seems like it is all too easy for those who are poor or mentally or emotionally challenged to fall through the cracks. By not taking care of such people, the government places a burden on family and friends, often the very ones that have little resources that they can share. They also have to worry that someone will not be there for them when they need help.
Ronnie Made Too Much - Ronnie is Medicare age but poor and unable to pay bills. He has been seeing me for about 5 years. He has chronic shoulder pain. He is on and off of Medicaid. He is self employed, doing various crafts. About 2 years ago he had a good year of sales and made enough to get him off of Medicaid. Unfortunately he was not able to get refills of his medications, including his ulcer medication. I can care for Ronnie just about every place he can call me, except from jail. Off of Medicaid for a few months and unable to get to our office for samples of ulcer meds, Ronnie nearly died. His duodenal ulcer was able to gain the upper hand and he perforated, nearly dying. For a few months off Medicaid, the hospital incurred over $15,000 in medical bills. Ronnie survived and continues on medication, but now the state restricts his usual medications for his arthritis pain. More paperwork might get these for him - an extra burden for me and my nurses. Now it is likely that Ronnie will be going back to jail. I gave him a note regarding his stomach condition to insure that he gets medications quickly, but the jails are notoriously slow in getting around to this. This slowness means that medical and mental conditions are more likely to interfere with the legal process, and more likely that the county will be stuck with a large health bill when the person really gets ill under their care, but those problems may not come until the person responsible is off duty, so why bother? Ronnie almost died because of such problems.
Mabel has TriCare. She cannot find a psychiatrist. Even when she does find one that accepts TriCare, she gets a call from the psychiatrists office canceling her visits. It seems she is too complex for the psychiatrist. She has chronic pain, depression, and marital strife. She has problems with her kids. She has to be supervised closely by her husband. As a couple, they often feel alone and isolated. She continues to see me, her family physician, for mental health, in between visits to the psychiatric hospital. Most would term her a borderline patient, but this is not my diagnosis. She can be manipulative, but responds well when I turn down her requests. We have had a rocky relationship over 3 years, but it continues to improve. In the past I have recommended that we not work with TriCare. When I was doing managed care work on a grant, our consultants consistently noted that TriCare was the worst in the business. From my perspective and those in my office trying to get consultants, pay, prescriptions, and information, this seems to be true. Mabel is no better in the past 5 years, but her marriage is intact and she is alive. Sometimes I wonder what would have happened to Mabel as well as another patient like her (Erica) if we had decided not to do TriCare or I had decided not to take her back as a patient and they were forced to try to get care through another physician. I know that I would have been more efficient and my office would have run better without TriCare and Mabel and Erica.
John Spends Down John is a physician and a state employee. He has with Blue Cross insurance. His daughter Elie was adopted at age 11 months. She is now a young adult. She has attachment disorder and depression. She has attempted suicide and been admitted to inpatient care in Nebraska twice for care. At one point she took so much drugs that she was comatose in the home of another drug-impaired teen. She somehow survived and made it home. When she again risked her life with drugs, suicide, and running away, John and his wife sought care for her in Austin Tx. The initial week of care had preapproval. During this time Elie did not improve and even wrote notes intending suicide even as late at two months into hospitalization. Blue Cross Nebraska attempted to dismiss the care by asking for records to review with only 24 hours notice. The facility scrambled and provided the records. The care continued for months. Blue Cross Texas authorized payment for the care, however Blue Cross Nebraska reviewed the care after discharge and decided segment by segment that the care in the hospital was not needed, despite their own reviews in Nebraska and Texas. Blue Cross noted that she was stable enough for less intensive care. This decision was not the same one determined by the hospital staff and doctors caring for Elie in Austin or by John and his wife. Appeals were not successful. Despite their professional degrees, John and his wife were not sharp enough to have attorneys and were still emotionally ill equipped to deal with Blue Cross. The care of such a family medicine can be overwhelming. John turned to the state for help. The state insurance investigators declined to investigate, stating that they could not help without additional information not available to Blue Cross. Clearly the information provided noted that Elie had had significant care before hospitalization. John and his wife had already involved daily tutors, monthly psychiatrists, in addition to therapists two visits a week. They were taking turns sleeping at night to supervise their daughter to attempt to keep her safe during her troubles. She found a window of opportunity from 4 - 6 AM and even managed to slip out regularly during this time without her parents knowing. Elie had already been in private residential treatment for two years and had only been home a few months before readmission to the hospital. Obviously outpatient and residential treatment had not worked. Despite this maximum outpatient care and the continued risk of drugs, depression, suicide, and self-mutilation, Blue Cross refused to pay for care beyond the first week. At this point Tracy was barely functional, yet according to Blue Cross, she was deemed ready to return to a less supervised environment. Even after 3 months, she was still suicidal, according to letters she sent to a friend. After transfer to a less supervised facility some 6 months after hospitalization, she managed to experiment with drugs and sex. She was transferred to a more supervised location.
This was not the first time for John to have blues regarding the Blues. Blue Cross delayed processing mental health claims for psychiatric care for over a year from the previous residential treatments, delaying payment of thousands of dollars. Blue Cross lost a $6000 claim for intensive outpatient care for Elie taken in June of 2001. Only a later communication with the facility noted that Blue Cross had attempted to process the claim at all. The family has also had difficulty getting claims from Colorado, Missouri, and Minnesota taken care of. John suspects that Blue Cross Nebraska has a policy that discriminates against out of state claims.
Despite a combined income of well over $100,000, the take home pay for John and his wife is about $1500 a month, not enough to cover regular bills. In another state with better mental health coverage, John and his family would be doing much better financially. In Nebraska he is refinancing his home and running up incredible credit card balances. Elie is so far doing well in long term residential treatment in Utah. John has little hope of recovering any of this $4000 a month. Mental health has cost him one year of the past 3 years salary and will cost him over $70,000 in 12 months time. Payments will come to mental health providers, but they will be delayed. John is much worse off over the past 5 years in Nebraska, financially. Fortunately Elie is much better, mainly because her parents have resources. Otherwise she would have likely been at the state youth detention center or she would be dead. She is isolated in a rural western state at a supervised facility. Some 9 months later she is beginning to come to her senses and is regaining the trust of those around her. This time it appears to be a real change as opposed to the many pseudo-changes that she has used to avoid increased attention and discipline. The situation for the 3 facilities is not good. The first facility for Elie got some pay from BCBS for the first week, but then BCBS Nebraska asked for this money back! They have yet to receive any of the $30,000 remaining. Try running any business with this kind of cash flow - a one year delay so confusing that you cannot even bill the patient! The second facility failed entirely, in some part due to difficult finances and an untimely attempt to expand to meet increased needs. The third facility is certified, but gets paid up front, a good policy given the mental health situation but a difficult one for those without means.
3 years later Elie is alive, sober, and continues to improve. She notes that the stimulant drugs took about 1 year or more to shake from her brain and system. So much for the 1 week paid by Blue Cross.
Now with the fiasco of Medicare Part D and further cutbacks and copays for Medicaid, matters are much worse. The poorest, least educated, most complexly ill are dumped on fewer and fewer willing providers, who are sinking fast under that added weight.
My observations over years of continuity with these situations:
1. There is little help for those in need of mental health. It is often too little and too late and not long enough. A few devoted and overworked people stand in the way of death or worsening disability.
2. The impact involves a great variety of people across wide socioeconomic strata.
3. Those who are nearly off state aid, often become deeply dependent again, instead of continued help with health coverage and making it off dependency.
4. There are unchecked abuses by insurance companies. Insurance companies know that smaller claims might be forgotten, or might be so much trouble that clients will give up. Often a lawyer might need to be involved, another barrier for those without means. Delays allow insurance companies to invest proceeds.
5. We as a nation are mortgaging our future in costs, increased costs to patients, trauma and poor health for their kids, increased costs for schools and prisons, increased likelihood that their kids will not graduate and will cycle into poverty, increased costs to the state as those in poor health are dumped onto state budgets
6. Medicaid policies encourage future dependency, particularly regarding coverage of teens and their new pregnancies.
7. Safety net clinics cannot survive in the new health environment. As they attract more and more complicated patients and receive no increased support for the care of such patients, they will have increasing inefficiency, declining quality, loss of providers, and eventual collapse.
8. Cuts in Medicaid only mean that payment will decrease, not health needs. Crisis care will likely cost more than regular care also. This also has greater impact on safety net clinics.
9. The stories make a strong case for single payer or universal health care. Such as system would need patients assigned to a regular primary care physician over a number of years. This would be most likely to improve health care quality, hold costs to a minimum, and not mortgage the future of our patients, kids, and the nation.
Reflections on the System
Robert C. Bowman, M.D.
UNMC Department of Family Medicine Director of Rural Health Education and Research
983075 Nebraska Medical Center
Omaha, NE 68198‑3075
(402) 559‑8873 or fax at ‑8118
This document, minus Mabel and Ronnie and Michelle and the reflections addition at the end, was handed to Senator Chuck Hagel's staffers and various state people, including state senators, at a recent Hagel health policy panel at Creighton. Not much reaction so far. By the way, the patient perspective never came up at the first part of the meeting regarding health shortage areas. The mental health part did not come out either. I had to go see one of the following patients at 10 AM so I missed the second half of the Hagel session.
Hagel quotes at the meeting of note to me:
Health care is an indispensable dynamic in our lives..... Each piece, when you move that piece, affects the whole puzzle. Senator Chuck Hagel, August 27th, 2002 at Creighton Medical Center.
Terrence Padden, hospital administrator at Alliance, was the star of the first session. He noted that he surveyed his his physicians, midlevels, (all primary care) and staff at a meeting. None of them would consider health care careers and only 25% would recommend such a career to their kids. The responsibility, the attitude of government, the lack of resources, and the unbelievable paperwork were too much.
Why do we treat those who serve so poorly?
See also Practicing On Your Own Can Be a Challenge about debts and needs of community and challenges faced by doctors serving the underserved
See also items on difficulties in mental health in children at http://www.usnews.com/usnews/issue/021111/health/11kids.htm
Robinson WD, Prest LA, Susman JL, et al. Technician,
friend, detective, and healer: family physicians' responses to emotional
distress. J Fam Practice 2001 Oct; 50(10):864-870. [Grant No. RO1 HS08776.]
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