Category: Funding

Categories
Funding Homelessness Policy Public health psychiatry

Geriatric Homelessness and Medicaid.

I submitted the following as an op-ed essay, though neither local publication accepted it. (I understand: Many people have many opinions about all the actions and inactions happening these days.) The tie-in with Medicaid is important, though I more want people to know this: There are people who are old enough to be your parents and grandparents who don’t have a place indoors to call home.

A van has been in the same parking spot in South King County for over six months. Inside are unopened water bottles, packages of adult diapers, trash bags—and a man. He is over 70 years old. Though he isn’t sure what year it is or the name of the current president, he knows that he wants to live in an apartment. He just doesn’t know how to make that happen. 

In another city park in South King County, a woman sits alone next to a trash can. Her black wire pushcart is stuffed with plastic bags. The stink of urine that surrounds her keeps people away. The trees are bare, a cold breeze is blowing, and she thinks it is a Saturday in June. She is also in her 70s. She slept outside last night, as she has for several years. The only topic she can speak of with confidence is her pet cat.

These are not isolated tragedies. They are alarms. If Congress follows through on its proposed Medicaid cuts, more vulnerable older adults—including those with dementia—will be forced onto the streets. This is unacceptable.

Older adults with memory problems who live outside seem like exceptions. In fact, they are part of a growing population. The US population is older than it has ever been. The number of Americans over the age of 65 is projected to increase by millions in the coming decades. Increasing age is the greatest risk factor for the development of dementia.

The California Statewide Study of People Experiencing Homelessness revealed that nearly half of single homeless adults were over 50 years old. Of them, over 40% became homeless for the first time at age 50 or older. Many of these older adults are eligible for Medicaid because they are poor. If they had more money or support, they would not be living outside. 

Dementia, like other chronic illnesses, drains savings. The costs of care add up fast. In Washington State, in-home caregiving services average over $31 an hour. Facility-based care, such as an assisted living facility, is also expensive–nearly $7000 per month. Skilled nursing facility costs are even higher. Many older adults run out of money.

This is where Medicaid funding for long-term care comes in. The federal government pays for over half of these Medicaid long-term care services and supports. For many, Medicaid is the only reason they have a place to call home.

Cuts to Medicaid would slash payments to long-term care providers. Staff would be laid off. Facilities would close. What about those with no family support or money? They will have nowhere to go. We will see more older adults, including those with dementia, living outside. No one wants this. Right now, Medicaid is the last safety net catching older adults before they fall into homelessness.

It is possible that Congress will protect Medicaid funds directed towards long-term care. President Trump has said that his federal administration will “love and cherish” Social Security, Medicare, and Medicaid. However, proposals from Congress show a clear desire to divert funds from these programs that thousands of older King County residents rely on. 

The man in the van ultimately agreed to go to a local hospital for brewing medical problems. From there, he was discharged to a skilled nursing facility. He was thankful: This is the first time he’s lived indoors in years. Medicaid made this possible. 

The woman remains outside. Without Medicaid, thousands more older adults will join her. That is the future Congress is choosing if it cuts Medicaid. 

Categories
Funding Medicine Policy Reading

The Word “Mental” in Project 2025. (v)

The fifth instance of the word “mental” in Project 2025 is on page 518 in the section about the Health Resources and Services Administration (HRSA):

Withdraw Ryan White guidance allowing funds to pay for cross-sex transition support. HRSA should withdraw all guidance encouraging Ryan White HIV/AIDS Program service providers to provide controversial “gender transition” procedures or “gender-affirming care,” which cause irreversible physical and mental harm to those who receive them.

You can learn more about Ryan White, the person, here. (Learning both about him and how HIV is transmitted while in elementary school was revelatory for me. I learned how a disease can unfairly confer stigma onto people, even kids! More importantly, I learned that I could do something to reduce the stigma, like shake the hand of someone with HIV without fear.)

The Ryan White HIV/AIDS Program (RWHAP):

helps low-income people with HIV. We help them receive: 

  • Medical care  
  • Medications  
  • Essential support services to help them stay in care

More than 50% of people with diagnosed HIV – about a half million people – receive services through the RWHAP each year. 

We also help diagnose, treat, prevent, and respond to end the HIV epidemic in the U.S.

Notice how specific the target population is! The RWHAP provides more details as it relates to the Project 2025 recommendation:

Of the more than 561,000 people served by the RWHAP in 2020, 2.1 percent, approximately 11,600 were transgender. 

Thus, the Project 2025 recommendation is specifically aimed at these 11,600 people.

Are “gender transition” procedures or “gender-affirming care” controversial? Yes. Note that “controversial” does not mean “dangerous”. Pineapple on pizza is controversial. People have opinions.

Do “gender transition” procedures or “gender-affirming care” cause “irreversible… mental harm to those who receive them”?

Let’s see what the research says. The data to answer this question isn’t as robust as what is available for abortion. Because the study designs have weaknesses in them (e.g., not enough people enrolled; did not follow people over time; etc.), much of the research is classified as “low quality”. This is a fair evaluation.

Based on available data, the current consensus is that gender transition surgeries do not cause “irreversible… mental harm”. They rather seem to reduce distress, smoking, and suicidal ideation.

Only 15% of people who had gender transition surgeries about forty years ago responded to a survey. They reported high satisfaction, less negative moods, and reduced mental health issues. (What about the remaining 85%?)

If regret is considered “mental harm”, it also appears that the rate of regret following gender transition surgeries is less than 1%. This is far lower than regret following other surgeries that have nothing to do with gender transition (around 14%). (Again, there are challenges with this data: How does one accurately measure regret? When there is no agreement about which tool to use, or no tool yet exists, it’s hard to know if you’re measuring what you want to measure.)

Hormone treatment, which has been studied more than gender transition surgeries, also does not seem to cause “irreversible… mental harm”. It seems associated with increased quality of life, decreased depression, and decreased anxiety for most transgender people. How does this happen? One pathway seems to be through reducing gender dysphoria, body dissatisfaction, and uneasiness.

It looks like there isn’t enough data to state with confidence that either intervention — surgery or hormones — reduces death by suicide. (Suicide is a relatively rare event. However, transgender people are far more likely to think about suicide compared to cisgender people, gay or straight.)

We return again to an important caveat about scientific research: It looks at populations of people, not individuals. Are there people who underwent “gender transition” procedures or “gender-affirming care” and suffered “irreversible… mental harm”? There is probably at least one person who would say yes.

However, from what data is available, it looks like most people who undergo gender transition surgeries and hormone treatment do not experience mental harm and, in most cases, experience improvements in their mental health.

The phrasing “irreversible physical and mental harm to those who receive them”, troubles me, too. This makes it sound like people who undergo these interventions have no agency, that they have no say in what happens to them. People choose to take hormones or undergo surgery. There are gatekeepers to these interventions.

The strenuous objection that some have to the mere idea of “gender-affirming care” also puzzles me. People have preferences about their identities and they like receiving care that affirms these identities. For example:

  • If someone prefers to communicate in a language other than English, providing health care to them in their preferred language is affirming.
  • If someone prefers to work with a health care professional from a similar cultural background (and I’m not referring only to race or ethnicity — I’m including regional culture, age, communication styles, etc.), accommodating that preference is affirming and helps people feel more seen. (It’s often gratifying for the health care professional, too).
  • Heck, calling someone by their preferred name is affirming care. And while this can include pronouns, I’m actually thinking of all the Williams in the world who would prefer to be called Bill, the John Smiths who, upon greeting them as “Mr. Smith”, shoot back, “Mr. Smith is my dad! Call me John!”, and the people who prefer to be called by a nickname.

Going back to the original text, though:

First, RWHAP only pays for outpatient services. This means RWHAP funds could never be used for gender transition surgeries.

Second, Project 2025 authors may have included more recommendations elsewhere about prohibiting “gender transition” procedures or “gender-affirming care” for any resident of the US. (I can only tolerate reading this enormous document in small doses.) People who are eligible for RWHAP are, by definition, poor. Will the authors also oppose these interventions for rich people? (Does Project 2025 oppose the idea of transgender people only if public dollars are spent for their care? Or do they entirely oppose the idea of transgender people, even if they are millionaires or a billionaire?)

Third, we all, including the authors of Project 2025, must continually check our biases. All of us are prone to believe that “I make correct assessments“, when our assessments can be phenomenally wrong. Until there is more and better data, the assertion that “‘gender transition’ procedures or ‘gender-affirming care’… cause irreversible physical and mental harm to those who receive them” is false.

Categories
Funding Policy Public health psychiatry Seattle Systems

Crisis Care Centers Aren’t Enough.

The Tacoma News Tribune graciously agreed to publish an opinion piece an esteemed fellow psychiatrist and I wrote. I invite you to read the 500-word essay, Crisis care centers are important. But WA needs more to fill behavioral health gaps, directly through the newspaper (and show a local newspaper some appreciation through page views!). The piece has particular relevance to residents in King County in Washington State.

If you have more time and would like to read the original version, you can find it below. Thanks for your interest.

King County voters will decide whether to fund a network of crisis care centers in April. There are many reasons to support this: We all know people who have experienced behavioral health crises, including kids in school; colleagues at work; family members; and people we encounter in the community.

Because King County currently has only one crisis center, additional centers will help. However, the entire behavioral health system in Washington is in crisis. A narrow focus on these centers only may lead to even more people tumbling into crisis.

King County has explained that these five crisis centers will “provide a safe place… specifically designed, equipped and staffed for behavioral health urgent care. These Centers will provide immediate mental health and substance use treatment and promote long-term recovery.”

If crisis centers have the most resources, they will be the most robust and responsive element of the system. Outpatient clinics providing earlier intervention and prevention services are often understaffed and have waitlists. People already enrolled in these clinics may wait weeks to months for follow-up appointments. Those leaving hospitals also compete for clinic appointments. This excessive waiting can precipitate crises. People should not have to be in crisis to access care.

Crisis care centers are designed to accept anyone, with or without insurance. Many behavioral health clinics have insurance restrictions. Some clinics don’t accept public insurances like Medicaid or Medicare. Others do, though have limited funds to provide services for uninsured people or for those ineligible to obtain insurance. Such restrictions will funnel uninsured people to the crisis centers. Yet, where will they go for ongoing care?

Due to limited resources, crisis care centers must screen and triage referrals. If people experiencing symptoms related to mental illness or substance use don’t meet criteria for admission to a crisis center or a hospital, what then? If under-resourced outpatient clinics remain understaffed or close, these individuals will be forced to wait for treatment. Their symptoms may worsen, precipitating preventable crises, which no one wants.

The option for people to stay up to 14 days in a crisis care center can help people connect to ongoing services. However, many agencies are unable to see people and establish care within 14 days, in part due to what King County described as: “The behavioral health workforce is strained under the magnitude of the need, all while being underpaid, overworked, and stretched too thin.”

The levy touts the use of peer counselors in crisis centers. Peers with lived experience are valuable, though should not be the primary providers of care. Peer counselors often have the lowest wages and, in some for-profit models, make up the bulk of personnel, presumably to maximize revenue. Some people in crisis are among the most vulnerable, ill, and complex patients in the region. Both patients and staff across the entire continuum of care deserve sufficient support and resources to get, and stay, out of crisis. If people experiencing mental health crises receive insufficient services, they are more likely to fall back into crisis and return to these centers. If these crisis centers are operated by for-profit organizations, readmissions will increase their revenue. We have already witnessed this pattern in several for-profit psychiatric hospitals where patients experienced harm. Patients and their families deserve better.

King County needs crisis centers, but personnel in other parts of the system also need support. The levy notes that funding for residential treatment facilities will focus on capital and maintenance. Building conditions are important, though the staff who work in these buildings are just as valuable. Many individuals receive ongoing care in residential treatment facilities following acute hospital treatment. Supporting and retaining staff in these residential programs are vital in reducing behavioral health crises.

Outpatient clinics with robust funding for personnel, technology, and other resources, along with appropriate reimbursement of services—things that never happened after the original deinstitutionalization movement of the 1960s—will help people access care. This, along with preventative efforts and early intervention at the first signs of behavioral health challenges, decreases crises.

Ultimately, supporting peoples’ basic needs will reduce the need for crisis centers. Living wages, affordable housing, access to food, universal health care coverage, employment opportunities, education and training, and building social connections, will reduce psychological burdens and promote wellness. 

This levy should be viewed as an initial investment in improving our battered behavioral health care system. More needs to be done to improve the mental health of our friends, family, and neighbors. 

Categories
Funding Homelessness Nonfiction NYC Policy Reflection Seattle Systems

God’s Work versus Meaningful Work versus Value.

Every now and then, when some people learn what kind of work I do, they say, “You’re doing God’s work. Thank you.”

They mean well, so I accept the compliment, though I also tack on, “I also like what I do. It’s meaningful work for me.”

So many of the people I see, whether in my current job or in my past jobs working in other underserved communities, have a lot going on that psychiatry and medicine cannot formally address. One example is housing. It is often an effective intervention for the distress of people who don’t have a place to live, though housing is not something physicians can prescribe. However, there are individuals who are eligible for housing, but do not want to move into housing for reasons that do not make sense to most people. For example, in New York I worked with a man who would spend his days sitting in front of the building where he once worked before he became ill. He talked to himself and burned through multiple packs of cigarettes. He did not recognize how soiled his clothes and skin became with time. At night he disappeared into the subway tunnels and rode the trains. He did not want to move into an apartment until he was able to get his job back, even though he hadn’t worked there in over ten years. With time (nearly two years!) and unrelenting attention, our team was able to persuade him to try living indoors. He eventually accepted the key and moved in.

There are other active conditions that I do not have the skills to treat: Sometimes it’s institutional racism; sometimes it’s multiple generations of poverty. Both prevent people from accessing education, housing, and other resources. Do some of these individuals end up taking psychotropic medications due to the consequences of these systemic conditions? Yes. Do I think they’re always indicated? No.

Most of my jobs have been unconventional: I worked on an Assertive Community Treatment team that often provided intensive psychiatric services in people’s homes. I worked with a homeless outreach team and did most of my clinical work in alleys, under bridges, and in public parks. I worked in a geriatric adult home and saw people either in my office, which was literally the storage room for the recreational therapist’s stuff, or in their apartments if they were uncomfortable seeing me in the storage room. I was recruited to create and lead the programming for a new crisis center whose goal was to divert people from jails and emergency departments.

And now I work in a jail.

As time progresses, it has become clear to me that I have not had the typical career for a psychiatrist. I like that. However, I often also feel out of touch with my colleagues. I believe that they are all trying their best, but they don’t have the time to see how systems end up failing the most vulnerable and ill in our communities. They work in the ivory towers of academia and don’t seem to realize the dearth of resources—financial, administrative, academic—in the community. They work in private practice and don’t seem to realize how ill some people are and how we need their expertise. They work in psychiatric hospitals and seem to believe that some of these individuals will never get better when, in fact, they do.

Because much of my work has been outside of the traditional system, I consider myself fortunate that I have been able to escape the box of simply prescribing medications. Many of the individuals under my care do not want to take medications. Their desire to not take medications, though, doesn’t stop us from working with them. We meet them where they are at and remember that they are, first, people. As we are in the profession of helping people shift their thoughts, emotions, and behaviors, we believe that there will come a time—maybe soon, but maybe not for weeks, months, or years—that something will change. Just getting someone to talk to us becomes the essential task. This is true whether someone is in a jail cell, living in a cardboard box under a bridge, or residing in a studio apartment.

Should systems pay psychiatrists to do this work? Maybe it’s not “cost effective” because of its “low return on investment”. After all, this task of “building rapport” means psychiatrists aren’t working “at the top of their licenses”. If a psychiatrist is able to get people to talk to her and help them shift their behaviors, whether or not that involves medications, does that have value?

Does the psychiatrist’s efforts have value if it helps the “system” save money?

Is there value if it reduces the suffering of these individuals who have had to deal with police officers, jails, and living on the streets due to a psychiatric condition?

Perhaps my idealism blinds me. One of my early mentors in New York City often said, “I want the guy who lives under the Manhattan Bridge to have a psychiatrist who is as good as, if not better than, the psychiatrist who has a private practice on Fifth Avenue.” I couldn’t agree more.

Categories
Consult-Liaison Education Funding Medicine Policy Systems

The Value of Psychiatrists.

While slogging through a crappy first draft of a document about the value of psychiatrists in mental health and substance use disorder services, I did a literature search for supporting evidence.

I found nothing.[1. Physicians, as a population, don’t advocate for ourselves as much as we should because we’re “too busy taking care of patients”. This is true. However, our busy-ness creates a vacuum where non-physicians step in and make decisions for us. We then express resentment that we have to follow the edicts of people who have never done the work. If we did a better job of regulating and advocating for ourselves, we might not be in this position.]

“So how exactly are we helpful?” I mused out loud. Maybe we aren’t: There are groups out there who do not believe that psychiatrists can or do help anyone.

I am an N of 1. Therefore, this post is an anecdote, not evidence. Nonetheless:

Psychiatrists provide psychiatric services. These are increasingly limited to only medication management, which is unfortunate. Psychiatrists need psychotherapy skills—or, abilities to connect with people to build trusting and respectful relationships—to do effective medication management. I can write dozens of prescriptions and change doses as much as I want, but if the person I am working with doesn’t trust me, none of my tinkering matters.

When people think about medication management, they often think only of adding medications or exchanging one for another. Medication management also includes helping people come off of medications. This “deprescribing” also requires the use of psychotherapy skills: Some people feel great discomfort when coming off of medications. Sometimes the reasons are physiological; sometimes they’re psychological. Psychotherapeutic interventions and education are necessary in helping people cope with and overcome these discomforts.[2. For any psychiatrists out there: You could build an entire practice around “deprescribing”. This is one of the most common clinical requests I receive through my blog. I don’t have a private practice, so I turn all these people away. To be clear, deprescribing isn’t limited to private practices; I deprescribe in my clinical work in the jail.]

Psychiatrists often have the most clinical expertise. Most have had exposure to the spectrum of psychiatric services (in residency training) and thus have perspective about how systems work (or fail). Thus, psychiatrists can provide clinical consultation about specific patients and program design, implementation, and improvement. One example is the use of medication assisted treatment for substance use disorders. Certain programs or agencies may believe in abstinence only and will view medications as another misused substance. That perspective is not invalid, though giving people more options may help someone reach the goal of abstinence.

Psychiatrists can provide education to other staff to improve their clinical skills, which can elevate the quality of care clients receive across the agency. Psychiatrists can also provide leadership and influence the direction and ethos of a clinical service. For example, you can imagine how a psychiatrist might influence a service if he believes that the only way to help patients is to convince them to take psychotropic medications forever. A different psychiatrist who believes that employment or housing may be more effective than medication for some patients would provide a different influence.

Psychiatrists can triage patients who are in crisis. A roving psychiatrist on the streets or visiting people in their homes often can’t do things like draw blood, but they can assess people and circumstances to determine whether a visit to the emergency department can be avoided. Psychiatrists can also provide strong advocacy: Psychiatrists can work with law enforcement so that people who would be better served in a hospital actually go to the hospital, and not to jail. Similarly, if someone who has a significant psychiatric condition requires medical attention, psychiatrists can talk with hospital staff to advocate for this. Too many of us have stories about our patients who needed medical interventions, but others thought their symptoms were entirely due to psychiatric conditions.

Psychiatrists go through medical training and often have ongoing contact with other medical specialties. They are thus familiar with the practical realities of communication about and coordination of care for patients across systems. While overcoming the financial and policy hurdles to integrate care are important, the reason why integration matters (or, at least why I hope it matters) is to improve the experience for the patient. Administrators should consider the interaction and experience between the physician and the patient as paramount. The system should not sacrifice that relationship to make administration easier.

This is the message that all physicians, psychiatrists or otherwise, need to communicate to administrators. We don’t do ourselves any favors by assuming that people know what value we bring to patients or to the system. Sometimes it also helps to remind ourselves, too, so we can improve our work for the people we serve.