DSM-V: What’s at Stake?

The American Psychiatric Association is scheduled to publish its next edition of the massive manual of psychiatric disorders next year. Some changes were made at their Annual Meeting last week. Allen Frances has expressed some concerns in a New York Times op-ed.

A few reasons why we care what the APA says is a mental disorder:

It can influence what types of medications and treatments insurance companies will cover.

It can influence what doctors decide to do with any given patient.

It can influence how the law treats different kinds of problems. (One reason for throwing out a suit that alleged a video game maker was liable for ruining the life of a gamer who got addicted to playing it? Video game addiction is not a recognized diagnosis.)

It can affect how responsible people are considered for their actions. (And while having a diagnosis doesn’t qualify you for the insanity defense, it can act as a mitigating factor in sentencing.)

Not to mention the softer factors of telling people they have a disease or mental illness — when that’s debatable.

There are plenty more consequences — please chime in in the comments if you have thoughts!

Here it is. Obamarama.

Lawyer: I went through the transcript with a highlighter to mark places where he actually said something concrete. I got to page 3 before I found anything.

Nurse: Overall, I think he’s doing a good job with this– it’s actually politically quite a tightrope between being too vague and making concrete promises that have to be shifted in some way later, and this always bites you in the ass. That said, it’s kind of disapointing to see how safe the approach is. While I recognize that it is largely impossible to enact sweeping dramatic change in a democracy which is beholden to so many interested parties, I wish it wasn’t. There are so many roots of the problems we have with healthcare delivery that are not addressed in this proposal– in a way, we are treating symptoms instead of making smart lifestyle choices. But I suppose that’s inevitable. Sigh.

Here are the substantive points he made, one by one:

1. We’d better build on what we have, rather than trying to build a whole new system.
Lawyer: Agree!

Nurse: Reluctantly agree out of pragmatism, not true belief.

2. This plan has three basic goals.
a. More security and stability for people who have insurance
b. Insurance for people who don’t have it
c. Slow the growth of health care costs

Lawyer: He doesn’t say much about how (c) is going to happen…

Nurse: And indeed, a lot of the most promising ways to do that are not possible in what amounts to a conservative (in the true sense of the word) reform effort.

3. Insurance regulation:
a.companies can’t deny coverage for preexisting conditions or drop/water down coverage when you get sick.
b. No arbitrary limits on how much coverage you get
c. Limits on out-of-pocket charges
d. Routine check-ups and preventive care must be covered

Lawyer: I mean, yeah.

Nurse: Right, this should be obvious. It’s not, but it should be. Even if this was the only thing that changed, we’d be better off.

4. Rather than out-right legislating what insurance companies must do, we will make these above reforms requirements for joining the health insurance exchange. Companies will want to join it so that they can compete for new customers. The exchange will give customers bargaining leverage.

Lawyer: I think this is a sound approach. Better to make people want to do things your way than to try to force them. Anyway, it worked with the whole drinking age thing. As long as it actually works. And insurance companies do actually participate. And follow the rules. Anybody know how this is actually going to function?

Nurse: It’s a tasty carrot. Mmm. carrots.

5. Tax credits for individuals and small businesses who can’t afford insurance, based on need.

6. Immediate low-cost, minimal coverage for the currently uninsured.

Lawyer: Um… details?

Nurse: Provided by? And covering. . .? People who can’t pay are still given care, but they are generally bankrupted by it. Maybe we are just getting around that.

7. People will be required to carry basic health insurance (just like auto insurance.) Businesses required to at least chip in. (Hardship waivers.)

Nurse: This at least makes sense, if we are going in a insurance-based model (See my previous post for a little discussion on that).

8. (wait for it…) Yes, there will be a public option available as part of the insurance exchange. (As one of many options.) CBO estimates that fewer than 5% of Americans would choose this option. The option will be self-sufficient, relying on the premiums it collects.

Lawyer: Wow, that low estimate makes me super-nervous.

Nurse: I think this is an essential part of the plan, not just in what it will actually do, but in the message it says. I do worry that it won’t truly be self-sufficient because people who elect it may have reasons not to buy private insurance or may find it too expensive. Depends on how the rest of that regultion reform plays out.

Lawyer: That’s too bad. Because people seem to be saying that it’s going down the crapper.

9. This will be paid for by cutting wasteful spending we already have, rather than expanding the deficit. If the projected savings don’t happen, we’ll cut spending, rather than adding to the deficit. Medicare trust will not pay for it.

Lawyer: Sounds good in theory. But I have a feeling that substantial savings will take a long time. I mean, longer than four years. Because our spending is really wasteful, yes, but we can’t just snap our fingers and quit doing that.

Nurse: And this is one place where we really need a cultural shift to fix it. A cultural shift involving how physicians and patients conceive of thorough care, and how malpractice suits are both perceived and actually used. Which leads into the next issue.

10. We’ll have some sort of panel to reduce defensive medicine. HHS is going to handle it. (vague, fuzzy, proclomations.)

Lawyer: I want to hear more about this! Ring ring, hello, Kathleen? Can we talk?

Nurse: Again, this is a deeply rooted cultural issue, in a way. I think we need some good evidence-based practice here– which means we need some research.

Lawyer: cf. Stimulus Bill.

Nurse: I have heard vaguely about studies which show that high-tech intervention can actually be harmful rather than helpful– as in using electronic fetal monitoring, which has been shown to cause unnecessary c-sections with no better outcomes, yet it’s become a standard of practice. HHS, can you work on this angle??

11. Poor Teddy Kennedy! This was his dying wish!  Also, as he said, this is a moral issue, not just a policy issue.

Lawyer: Aww. Shot to the heart.

Nurse: Ok. Cool.

12. People thought we were socialists back when we invented social security and medicare, too, but can’t we all agree now that we need those things and they were a good idea?

Lawyer: JEEZ, thanks Obama, I’ve been trying to tell people that for a while now.

Nurse: well, what’s wrong with socialists? And another thing: he talks about requiring insurance to cover preventive care, but I think we could make huge progress by going a step further and offering incentives for preventive care. Maybe that would just be smart business for an insurance company, I don’t know– but i think it would help!

Lawyer: Mmm,  more carrots. Carrot cake. I have to go…


NurseA recent article in the Atlantic, by David Goldhill, discussed health insurance reform from an angle we haven’t heard a lot of: why do we expect all of our healthcare expenses to be paid for by insurance? Everything from a checkup to our daily prescriptions to our accidents to our catastrophic illness is, in most people’s minds, the provenance of insurance. This, he argues, has the effect of making the insurance companies, rather than the patients, the customers, and it throws the whole free-market dynamic off entirely. He proposes mandatory health savings accounts as another path. Now, there a problems there, too, and I don’t agree with many of his points, but he raises an interesting question. If we own a car, we are required to have car insurance– but that doesn’t cover new tires, oil changes, and the like. It covers accidents, liability, theft, and damages we might not be able to afford without it. Same with insurance on our homes, our lives, our possessions. . . but not our health. Of course, we’ve been in this system for so  long that most of us could not pay out of pocket for the majority of our health expenses, but the author argues, and correctly, I believe, that the cost of health care as billed to insurance companies and the cost of health care as incurred by providers and facilities is astronomical, and much of that cost is due to administrative nonsense and lack of decent competition and incentives to perform. Interesting, no?