Dr. Kali Cyrus is our February co-editor. This is part two of our conversation.
There is a lot of off the clock work happening, and out of pocket spending. So much of the care falls on staff after hours.
I would call it the out of pocket / out of office hours commitment. In terms of the costs to me, if I happen to be a doctor who gets bothered, a doctor who works in the public system, what ends up happening is most of my time is not actually spent treating the person's mental and physical health. It's mostly spent trying to figure out case management issues.
If we know this person doesn't have any food at home and they need to be taking their meds with food, or this person doesn't actually have a primary care doctor and they're smoking half as many cigarettes, which is usually the case, or their blood pressure is 200 over 120, or they keep getting hospitalized for medical reasons, if they're in a house dealing with trapping every night, they can't get sleep, it worsens their depression, and they're in a crisis and calling the cops, I can't do my job.
It isn’t really monetary, but as a team, we spend most of our time trying to figure out how can we get this person food when they may not be eligible to get free food from the state district, how can we actually try to get this drug dealer to forgive a debt – which is like, how can we do that?
What we end up doing instead of focusing on what kind of medications can I give you, or how can I meet with you on a weekly basis and talk through what you need to change, what is a path to recovery, is trying to manage the social stressors. It more so impacts social workers or people who've gone to school who want to be therapists, they end up being case workers. They end up doing these kinds of things, you can talk to them and use your therapeutic knowledge in that way, but it's a very different job that requires a lot more patience because you're dealing with systems that are so non functioning.
It's like going to the post office every day and getting in line for eight hours.
It's essentially what that part of the job has become. I think the other end of it, if you think about teachers who end up spending their money to buy supplies, that type of stuff, I don't necessarily end up in that position because I'm the physician. That's something a lot of us have very strict boundaries about. If I have a patient asking me for food, I'm at a clinic or I'm at their house, I'm not going to. No one would expect me to go run to the grocery store. That's going to fall on my staff. If my staff goes to see them three times a week, they're the ones who are going to get asked for money three times a week.
Think about people who work in group homes, where you have mental health patients with people who have other physical or mental disabilities, staffed by people who are not necessarily nurses. One, you're not making a lot of money and you're supposed to be in house with them all day, those are the clients saying, "I need a cigarette, I need a cigarette" when they've already used up all their cigarette money. But if they're going to flip, they're going to punch you in the face because they have a psychotic illness and they don't have the insight into knowing that you can't just give them cigarettes, cigarettes, cigarettes – they'll go buy them cigarettes if that's the thing that's going to keep calm.
Thinking through the costs in that way, is something I've learned from, and the way I've tried to help my staff out is however I can apply to services for them. I have some people in D.C., once I find out that they're at an age where they could potentially qualify from a home health aid, I apply to everything. I try to get them meals on wheels. I try to get them this thing, that thing. Many of them have been denied in the past, maybe they haven't really tried, or maybe they aren't eligible, but the main way is to try to get them as many services as possible, which then leads to complicating the treatment because you have four or five different agencies involved, and you're trying to figure out who's doing what, which is a different problem, but a better problem to have.
For the most part, the out of the pocket comes from my case workers. You end up spending a lot of money to help the system function to help your patient.
What needs to happen for these systems to work more cohesively?
I think about it as large group solutions and smaller more immediate solutions. In terms of the large overall solutions, I think crisis, I think crisis settings. I really believe in the urgent care system. If you're having a crisis right now people come to the ER and there's no beds to send them to. No long term hospital spaces. Not everybody needs to be in the hospital for seven days a week, 24/7 to be monitored.
We can move them to this middle unit where they can be kept safe for a little while. Some of them just need to get through the weekend. Observation units that aren't hooked up to all the expensive hospital bays are really great places, and then a lot of people can go home after that. They might not need the five days, they just need a couple of days. And I've found that that's a good workaround of not having inpatient beds.
I've also found that outpatient urgent care settings are good. It's a nine to five clinic, with staff, social workers, usually one physician, some peers. You can walk in off the street. It's an outpatient model, imagine how much money you save in that.
You can deal with the multitude of crises by having some place where you know you can go that's not waiting in the ER for eight hours.
In terms of the large system, it's groups. If you're not going to magically be able to reimburse every psychiatrist or every outpatient, why don't you have more groups of people, who once they leave the hospital just need something from six to nine. Think about AA in terms of mental health treatment, they need other people who are going through the same things they are that are staffed by social workers or staffed by psychiatrists who can provide ongoing care for them, in a model that's in a community center somewhere. That's not expensive and something the state can pay for.
Imagine the quality of what you could have at that time. It's not one reimbursable, so it's not there. Obviously the other individual level solution, you need a meals on wheels program or functioning transportation to help people get to appointments. You could even put a psychiatrist or psychologist in primary care offices.
My simple answer is how do you incorporate mental health players in these spaces? Making sure you at least know there are places that you can go. That takes investing in social services not just mental health centers. It's investing in the community itself.
Dr. Kali Cyrus is our February co-editor.
I’m Kali Cyrus. I'm a psychiatrist in Washington D.C. I finished residency around 2017 and moved to D.C. in 2018. When I started working in this setting, I had just moved from Connecticut and finished about a year on the Hill working for a Senator [Chris Murphy]. I finished a fellowship through the American Psychiatric Association. They pair you with someone and you essentially work as a staffer. I finished doing that before I started working here at this clinic.
I was just doing this a couple of days a week, it was supposed to be a six month contract, I was going to be moving on to another job in Virginia. This was a way to bide my time, but I ended up loving the setting, feeling really passionate about the patients and the team that I was working with, and recently signed on to be full time. One of the things that made me want to look more into this was working on the Hill. I've just recently found my perspective on how many barriers are ridiculous, people don’t understand the minutiae of it.
I'd come from a different system in New Haven, Connecticut, which has a really good state public mental health system – I only realized in coming to D.C. I have the benefit of prior experience to see what systems do differently and how things could be functioning here. I was caught extremely off guard, and was surprised by how nonfunctioning the system was. I’m trying to find some answers myself, which worked out well to work with someone trying to also.
What does the dysfunction look like?
It's funny, when I first moved here, I was working at Senator Chris Murphy's office who's from Connecticut. I saw him at an event and told him how the system didn't function so well. He said, "You were always telling me how bad the Connecticut system was." And he laughed at me, and I realized what I think I know – I try to be as objective as I can.
One difference is that the state of Connecticut, like most States, run their public mental health system. They have a number of state sponsored clinics throughout regions of the state. Everyone who runs that clinic system in that area meets on a regular basis and acts as mom to all the hospitals. The long term state hospital and all of these centers are modeled to function the same way, depending on the population you're serving. You usually just have a clinic where you go for urgent care. If you don't know where to go, you can show up between nine to five, get an evaluation, and they will hold you in that clinic until you find a provider if you have insurance, or they'll transfer you up to their team.
Some have integrated medical offices. The one in New Haven I worked at had a primary care hub in it, and they have a 3-1-1. Everyone has one of these. It’s where you call if you're suicidal, or you need to talk to someone, and they're usually connected to some sort of local state psych hospital. A lot of these clinics have an ACT team.
ACT is a community treatment model that is national, these are patients who are kicked out of every clinic, because they won't make it to appointments. It’s mobile crisis essentially.
Where I worked in New Haven was special because we also had a partnership with Yale, and were staffed by residents, staffed by psychiatrists who were also faculty at Yale – social workers, psychologists, psychiatrists, and providers who were actually paid by the state of Connecticut. It was a public private partnership. It was definitely a wealthier system. It was more functioning because we had a lot of manpower.
As it turns out in D.C., most of the community health work is done by either nonprofit or for profit core service agencies. That's the difference. Much of the care is provided by entities that have a profit driven motive – you need to stay afloat.
It's well known in psychiatry that you lose money. You can't really make money off of psychiatry.
If I back up, D.C., District of Columbia, is not a state. That's something to keep in mind. They pay organizations, called core service agencies, to provide services. While this may be a private nonprofit, you're still run by the state. You can imagine that your profit motive is different because you are accountable to the same standard group.
The agencies vary in what they provide. If you're a bigger core service agency, you not only offer psychiatric services, you may also offer vans. You pick people up – if the city pays you to see one of your clients, through Medicaid & Medicare, you know you can say, "I'll take them.” You make more money because you have the van. You can continue to transport clients where they need to be – transportation is a huge thing. Otherwise, you have to rely on the Metro system and specialized forms of medical vans. But these agencies can also then say, "Well, we also have some group homes." If a client goes with them, they can house them in homes that meet every service, and pay staff members to be there around the clock.
They might also have Home Health Aides. Their own nursing staff, which are usually people with a bachelor's degree, not nursing degrees, who sit with patients all day.
The key is that D.C. is a decentralized community treatment model, which means people who are in crisis fall under the responsibility of the core service agencies and the community.
In Connecticut you go to the closest hospital, then to one of the state public outpatient centers. In D.C. they have one centralized health point triage, that is in an office building. I'm used to the ER – where someone from a psychiatry team will evaluate you with a social worker that night, and then decide if you're in crisis, get you hospitalized.
The biggest difference is when clients are in crisis in Connecticut, we're able to get that person hospitalized. In D.C. they would go to the triage center, CPAP, to be evaluated. Everyone has to go through there and if they need to be hospitalized, it's more than likely not going to happen, because there are not a lot of places to go. The standard here is not to encourage you to go to hospitalization. They hold you in this triage center – and of course you calm down, you're in a structured environment, you're not on the street with all the stress, and then it’s "Oh you've calmed down" and you let you go. You literally have to be a danger to yourself or others, say you're going to kill someone.
Everything is state by state. What are some of your overarching concerns in the U.S. pertaining to mental health? Especially in patients where their living situation is chaotic, dangerous, or unpredictable?
Think about it in terms of, are you in crisis, and how do we keep you out of crisis?
The biggest concern in keeping people out of crisis is that they need to be treated by people.
They need a psychiatrist or a clinic to go to. They need someone who can give medications, or therapy, to keep them from being in crisis. For people like you and me it's tough to find a psychiatrist! The first thing people say to me when they learn I'm a shrink is, "Oh my God, I need a psychiatrist so badly." Especially if you're a person of color or another minority identity, you're probably looking for someone who looks like you. For whatever reason people can't find us.
That's because the healthcare system does not reimburse mental health treatment at the same amount that it does for physical health.
If you break your ankle, it's pretty straight forward. You go to the hospital, they wrap it up. You may need surgery, you may need an MRI. Those doctors are going to get paid, that ER is going to get paid. Those x-ray technicians are going to get paid. It's clear.
Psychiatry has always been a bit of the bastard of medicine in that an emergency is fuzzier. It's like, "Oh well this person is high. Maybe that's why they're violent towards themselves." They don't have clear standards to reimburse because that looks different across States.
Someone who's high, someone who wants to die, or someone who's depressed, looks so different. To be able to say, "You should get reimbursed at this amount" you would need so many different scales – we call this issue “paired”. People talk about this in policies, that there's no mental health care. There's no mental health period. That essentially means mental health and behavioral care does not get reimbursement from Medicaid, from Medicare, or even your private insurance. What happens is that most people don't participate. Psychiatrists don't work with insurance companies, don't work with Medicaid, don't work with Medicare, don't work with Blue Cross, because you're going to get a reimbursement of $20 when you could be charging out of pocket.
We also have non-visible communities that don't have people around to show what it looks like to get preventative screenings in mental health care. This is probably more visible as it pertains to substance use. You have so many people trying to get sober, but where do they go once they get sober? AA? That's all we know.
What doctors are seeing, what psychologists are seeing, is a reliance on the ones who are available, which are typically publicly provided.
In the eighties mental health treatment moved to this model of not wanting people to be locked up, to be in straight jackets, to be in jail, mental health prisons, which is a very worthy goal they're advocating for. We shouldn't just keep it as the hospital. But what happened was that everything was deinstitutionalized. The community will take care of you, but they never set that up in the community. A lot of people aren't in favor of hospitalization, but that's actually the backup in crisis.
The second way of thinking through this is, what happens when you're in crisis and, as it turns out, because we deinstitutionalized our form of care, we can't rely on structures that were in place, we're relying instead on community structures that were never put in place. If you're in crisis, you need to be watched 24/7. Think about a friend who's depressed, who's suicidal – you might sit up all night and watch them if this is your partner, if this is your mother. But are you going to be awake 24/7? That person could wake up, grab something out of the medicine cabinet and hurt themselves. That's why they need crisis care.
There's a third category of people who for mental health reasons aren't showering, aren't taking their medications – people living with their parents, living with their friends, and are deteriorating. Who's going to make them eat? It's quite paternalistic.
Again, if you're not being reimbursed at the same level as other specialties, that means you're not making as much money as a system, which means it's usually the mental health part of the hospital that loses money. If you're going to run this kind of shit for crisis, you know you're going to lose money. If they are available, and functioning, and making money, they're probably private hospitals – that's where I would end up. My insurance would pay for me to go get hospitalized day to day at a fancy private hospital that is going to make money, which means my insurance company, because I have good insurance, will pay the hospital more money or, I will pay someone out of pocket if need be, to make sure I have care. Those are the hospitals that end up doing really well.
What happens if you don't have the private hospital? What happens if you have a public hospital but all the beds are full? You end up having people at ERs. That's actually what's been happening in recent years.
We're having a crisis in our medical ERs.
People show up to the hospital because they need help, they get to the ER and there's nowhere to send them. So they sit in the ER bed for a day, a few days, up to a week. I've seen people sit in this little ER room waiting for another spot to open.
So what do you do? Each State has its own struggle depending on where they decide to invest their resources and money. One aspect you see that’s surprising to me, as maybe a naive, idealistic person, is that you have Medicaid and Medicare that reimburses pretty well for outpatient community, but there are field players taking advantage of that system, making money, but not provide a level of care that keeps people out crisis. That's what I've seen to be happening in D.C.