Wednesday, January 20, 2010

Back in Minnesota: Opportunities and Barriers to Change

Blog entry 1-20-10
Well, it’s been over a month since I entered something in my blog. (I’m sure the millions of faithful readers have been wondering what happened.) Well, two things. The holidays. And re-entry. I’ve been negotiating re-entry into my family, my home in Minnesota, into the professional community of St. Paul-Minneapolis, and into a local health care organization (HCO) called Allina. Paul Goering, a psychiatrist and director of mental health services for Allina (a collection of hospitals and clinics in the metro area) was kind enough to not only give me a job on my return to the Twin Cities, but he also has recognized an opportunity to change the way we treat addiction. He has said repeatedly that “the way we treat addiction is not satisfactory” but that up to now there haven’t been any alternatives. Paul, besides being a really nice human being, is a skillful administrator who has made my return here much easier than it otherwise might have been. In addition, someone else I met this fall, Bobbi Cordano, is a human dynamo who serendipitously became the interim director for something called the Center for Clinical Innovation at Allina. The Center is still finding its way, but it’s devoted to supporting innovation in the delivery of services, particularly as they affect the broader community. She and I have also been talking about ALATYR, my initiative to change the way we treat addiction in America, and how we might work together to make it happen.
I have encountered other opportunities as well. The state of Minnesota Department of Human Services is interested in looking at ways to improve addiction treatment and I am in discussions with them about how to make it happen. Upon returning to Minnesota, I have been very impressed with how progressive the medical community is here, and how much the various health care organizations seem to be focused on improving care more than on making money (although they of course have to do that.) The fact that HCO’s in Minnesota have to be non-profit by state law may have something to do with this, but Minnesota also has a tradition of progressive politics and a communitarian focus. All in all, it appears there are many potential opportunities here to try out my ideas about a public health approach to substance use.
It’s also been interesting to practice in a private HCO in a highly managed care environment. Minnesota, Massachusetts, California and Seattle have led the nation in early penetration of managed care and at least in Minnesota virtually all health care is managed. (In contrast, in Washington, DC, it seems that very little of it is.) I had a small self-pay private practice in Washington before moving back here, but this is very different. And it’s giving me insight into some of the problems with our current system.
For one thing, the incentives are all wrong. I can only get paid for face-to-face time with patients, even though it would be more efficient and effective to work with a team of professionals such as nurses and therapists who provided various parts of care. Reimbursement for psychiatrists is greater for medication management alone rather than combined treatment with psychotherapy and medication management, which in my experience is more effective and is strongly preferred by many patients. A great deal of time (and money) is spent by multiple people to meet bureaucratic requirements of insurance companies and Medicare, while providing no benefit to patients whatsoever. There is no incentive to provide better outcomes, and in fact no measurement of outcomes. There is no incentive to provide better care or care based upon current evidence. Patients and families are left to their own devices to figure out where to get care, and who might be better at particular types of care, other than the annual “Best Doctors” issues of local magazines. In short, the current system with all its many interlocking components makes it extremely difficult to do the right thing. In my experience, it’s the system that determines the quality of care, not the individual provider. If we can’t line up the incentives more rationally, we are doomed. I must add, parenthetically, that the individual professionals at all levels seem to be devoted, careful clinicians and support staff who truly believe in what they do and want to provide the best care they can. The problem isn’t the people in the system- the problem is the system.
In the next few postings, I’ll share further experiences and insights as I care for patients and interact with the HCOs and government.

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