October 21, 2009

How Am I Going To Get Paid If It Isn't Autism?

But many children whose symptoms significantly differ from classic autism--who belong only on the milder end of the autism spectrum, if they belong anywhere on the spectrum at all--are inaccurately ending up with serious autism diagnoses.

Wait: it isn't what you think.

In The Atlantic, Behind The Autism Statistics:

So parents whose kids' challenges are less severe are often urged to accept a full-fledged autism diagnosis, as otherwise they would lose access to state-funded treatment, and might, down the line, end up ineligible for support services in public school.   The result is that the autism statistics grow and grow.

In diagnoses without obvious physical pathology (i.e. anything in the DSM), doctors often give a diagnosis to a person with the express purpose of getting them benefits, e.g. Medicaid, school  supports, etc.

The Atlantic hints at one side effect of this: the national statistics for psychiatric diagnoses may be inflated.  I'll editorialize: not maybe, but absolutely are; we can't get paid un;ess we bill a diagnosis.  In the chart we may write, "rule out MDD" and in the note indicate they were normal, but epidemiological studies don't read notes; they take billing diagnoses or look at the listed Axes.

This is compounded by "awareness"-- as more people hear about a diagnosis is, and they come in for an eval, their very presence contributes its prevalence even if they are told they don't have it.

II.


The Atlantic spends the bulk of the space lamenting the inappropriateness of the diagnosis:

[Dr.] Greenspan told me on the phone, (and later on camera), "Basically we have to misdiagnose these kids to get them help."  It's the wrong help sometimes, but it's the only way to get state funding.
The concern isn't the state funding, but the odd way the government, e.g. Medicaid, covers treatments.  There are "approved treatments" for autism; any other treatments are out of pocket.  However, if you're not sure of the epidemiology, then you're not sure of anything else like treatment or  sequelae.  If the autism stats are skewed by the presence of kids with something else other than autism, then how can anyone say with any usefulness that "studies have shown that treatment X is effective"?   How can any government tell you what the best practices" are?

The article talks about Sensory Processing Disorder-- if the kid has it, he has to get an autism diagnosis to be eligible for services, except

...while [the child] was making some progress, the therapy didn't seem to be addressing his biggest problems, which involved motor challenges and sensory issues, rather than the kinds of social impairments typical of autism.
I know very little about this diagnosis or its treatment.  However, it's logical and obvious that its inclusion in autism will make a) autism treatment seem less effective; b) SPD treatments untestable.


III.

The article, and the supporters of "autistic-like" disorders, take (IMHO) the wrong tack: they want "Sensory Processing Disorder" to be included in the DSM, "which would turn it into an official diagnosis that would come with much-needed help."

That's the wrong approach, because it legitimizes the government's use of the DSM, and so every new treatment will have to wait for their blessing.   The better approach would be to provide coverage for treatments based on the recommendation of a treatment team, within the limit of a budget.  Instead of saying, "we'll cover this treatment at $120 a session but not this other", simply provide $120/session for any kind of treatment suggested by the team.

IV.

Here's the most important secret about Medicaid and Medicare: it isn't about improving health, it is about paying people off.

While the kid described above can only get the "approved" treatments for autism, he can get the approved treatments for every other condition as well:  surgery, eye evals, antibiotics for infections.  In other words, his "autism" got him full health insurance. 

Medicaid requires a "disability" and a very low income.  The income of the child's parents is irrelevant.  All kids with a "disability" (e.g. ADHD, depression, etc) are eligible for Medicaid and its services.  A child can get physical therapy, occupational therapy, speech therapy,  not to mention a prescription plan, doctor visits, etc -- all for free; never mind that the "child" goes to Eaton.  Certainly the parents' private insurance might cover these things but it might not.  Maybe the Dad owns a restaurant and doesn't want to pay for insurance.

If you have a 25 year old unemployed actor for a son who lives rent-free in your house and  spends your money on chest waxing and self-tanning cream, and he can get a doctor to believe this depresses him, he can get Medicaid.

Because a disability has to be verified by a doctor and updated over time, the patient's only  way of maintaining the coverage is to use it.  This happens all the time.  Patients will come once a month for visits, fill the Zyprexa prescription and then throw them out-- all to maintain their benefits.

Before you get angry, understand that this isn't a loophole, it is the point of Medicaid.  For a myriad of reasons we do not have universal (not single payer, but universal) coverage, which would have the (seemingly) paradoxical result of reducing healthcare costs.  But, surprisingly, we have a lot of poor people in the country.  The government has found a way to transfer to them just enough money and services to keep them from rioting, without calling it a transfer, without calling it socialism.  Simultaneously, it manages to pay doctors, hospitals, employers (through tax breaks), etc.  Where is all the money coming from?

Debt.


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A Boy With SPD?


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http://twitter/com/thelastpsych





Comments

If you look at the comments... (Below threshold)

October 21, 2009 2:48 PM | Posted by jessa: | Reply

If you look at the comments in the blog entry of mine I linked my name to, you'll see a discussion that parallels part of your entry right here: if diagnoses are going to be used, use them right or they become useless (well, beyond getting benefits). Gah!

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Can you please explain to m... (Below threshold)

October 21, 2009 5:23 PM | Posted by Anonymous: | Reply

Can you please explain to me how we could ever possibly have universal coverage without a single payer system?

I'll be waiting

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Universal coverage without ... (Below threshold)

October 21, 2009 5:51 PM | Posted by Z: | Reply

Universal coverage without a single payer system:

Government provides coverage for basic things such as check ups, preventative treatments, and relatively inexpensive procedures that can be done in such places as family practictioner offices or E.R's.

Anything else, such as major surgeries, long hospital stays, transplants, plastic surgery, etc, will require the person buy supplemental insurance. It is not paid for by the government.

"But that's not universal coverage!!" - That depends on your perception of universal coverage.

It does at least fill the requisite of not being a single-payer system.

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You forgot something Last, ... (Below threshold)

October 22, 2009 5:46 AM | Posted by Anonymous: | Reply

You forgot something Last, unlike real, measurable physical illness, mental illness is never cured. . If the patient gets "better", the patients mental illness is in remission. If the patient gets "worse" they need more drugs.

They will forever need help as they can't be cured.

A patient can keep sinning, stop sinning or sin again.

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There is also an opposite e... (Below threshold)

October 22, 2009 7:07 AM | Posted by SusanC: | Reply

There is also an opposite effect: if the patient exhibits symptoms of some other DSM condition and one of the pervasive developmental disorders, the psychiatrist may well officially diagnose the other condition and stop there, because that's enough to ensure the patient's treatment gets paid for, and they don't see any need to officially diagnose the co-morbid autism.

However, this really messes up the data for the researchers trying to do epidemiology.

If you want to know whether autism is statistically correlated with some factor X, I'd recommend re-measuring the autistic symptoms of a sample of people, rather than believing their offical DX.

It's less of an issue with autism, but some patients fake symptoms in order to get a prescription for a drug they want (e.g. amphetamines). So if you're doing epidemiology, it's a good idea to base your statistics on research diagnoses made in a situtation where the patient knew they weren't going to get free speed if they faked the right symptoms. (Obviously, it's too costly to do separate research diagnoses for every patient, but for the statistics you only need a random sample).

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Linked:<a href="ht... (Below threshold)

October 22, 2009 12:43 PM | Posted by PPB: | Reply

Linked:

http://privatepracticeblogs.blogspot.com

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"sensory processing disorde... (Below threshold)

October 22, 2009 5:23 PM | Posted by medsvstherapy: | Reply

"sensory processing disorder:" --google it and read the discussions. this phenomenon is just like the adhd and bipolar phenomenon. the problems/symptoms the majority of cases that moms are blogging about will flip you out. "sally absolutely has to have her sweater inside-out, and her peas cannot touch her carrots. she must watch thomas tank engine twice before she will go to bed." the more accurate name, in a lot of these cases, might be "indulgent parent syndrome."

Why is it that I cannot think of one person I know personally, from my personal versus professional life with SID? I know a few ppl from personal life with schizophrenia, bipolar, MDD, narcissism, BPD, (real) autism, various substance abuse and dependence, in spades, OCD, GAD, agoraphobia, and more. But I cannot think of anyone with SID. Except one indulged child who will not eat tomatoes.

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Universal coverage could... (Below threshold)

October 23, 2009 10:26 AM | Posted, in reply to Anonymous's comment, by Alone: | Reply

Universal coverage could be done by mandating everyone buy private insurance, and the government subsidizing the cost for those who couldn't afford it. In this manner, there wouldn't need to be any "public option."

However, whenever a government promises to pay for a private service or product, the price always goes up: there's no incentive to reduce prices or costs because the government always pays. This is why college tuitions are high: guaranteed student loans. No risk to the college-- they're going to get paid, GUARANTEED; but the student carries all the debt. (Until they default, and then it's everyone's problem-- except, again, the college's.

So it could be done, but it's not a good idea. The only viable mechanism is one in which people are either given a budget, or incentivized towards cost reductions. So insurance where the doctor works within a budget.

I'm for a public option, but I am not for a Medicaid style one. Consider the lament of docs that they are being paid less than they were 50 years ago. True-- per patient. So instead, to make up for it, they set up six rooms and spend three min with each one, and the nurse handles the rest. Medicaid forces docs to think about volume, not quality. This isn't a slam against the docs, it's the system they're stuck working in.

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Universal coverage could be... (Below threshold)

October 23, 2009 1:47 PM | Posted by Bob Watson: | Reply

Universal coverage could be done by mandating everyone buy private insurance, and the government subsidizing the cost for those who couldn't afford it. In this manner, there wouldn't need to be any "public option."

--This is the system in Germany.

However, whenever a government promises to pay for a private service or product, the price always goes up: there's no incentive to reduce prices or costs because the government always pays.

--The German government negotiates annually with the private insurance companies what will be paid per procedure. Then the price don't always go up.

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"sally absolutely... (Below threshold)

October 27, 2009 1:57 PM | Posted by SusanC: | Reply

"sally absolutely has to have her sweater inside-out, and her peas cannot touch her carrots. she must watch thomas tank engine twice before she will go to bed."

That sounds almost exactly like the symptoms you see in cases of autism and OCD ... and in either autism or OCD, it's rather more severe than the patient just being over-indulged.

"Sensory processing disorder" seems to refer to an autism-like condition where the sensory impairment and obsessive compulsions are more marked than the theory-of-mind impairment.


If you have 3 checkboxes for sensory issues, obsessive compulsions and theory-of-mind impairment, that gives 8 possible combinations. I've seen real instances of most of the combinations except sensory issues only - but I'm quite prepared to believe it exists.

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<a href="http://www.amazon.... (Below threshold)

November 6, 2009 10:39 AM | Posted by Nancy Lebovitz: | Reply

Too Loud, Too Bright, Too Fast, Too Tight is a book about being highly sensitive to stimuli that most people are comfortable with or can ignore.

It seems plausible to me that there's be enough human variation that some people can't handle "normal" stimuli. I'm not in the diagnosable range, but loud music that almost anyone can enjoy is really painful for me. I wouldn't be surprised if there are people who find the texture of clothing labels to be intolerably distracting.

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I disagree. Psychological a... (Below threshold)

September 15, 2010 12:40 PM | Posted, in reply to Anonymous's comment, by Ricardo Mann: | Reply

I disagree. Psychological and psychiatric illness, when symptom free can be referred as remission, or as cure. A patient with severe depression get better, he is cured. Depression is no necessarily a personality trait, but rather a condition onset by a particular episode.
Given this the way that medicaid works perpetuates the illness. If the patient has to prove that they are sick in order to get the required benefits, they cannot improve gradually to the point where they require less benefits, but still require part of the treatment.
This is the big difference between having medicaid and medicare, private insurance, and single payer system. With the single payer system, the diagnoses determines treatment, not bureaucracy. Mix system of single payer (lousy label for government option) and private insurance is the way to go if what matters is health (and it would drive the cost of insurance down).

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leather bomber jackets and ... (Below threshold)

June 3, 2013 7:31 AM | Posted by Nadia: | Reply

leather bomber jackets and flight jackets made in the USA,Nylon Bomber Jacket fit the bill quite nicely.
However, it had an ancestor, a forefather so to speak ---the Military B10 and B15 Canvas Service Jacket.

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