Reader Dan on Combat, PTSD and the US

This one is by Reader Dan

Adopting best practice procedures in our healthcare system is complicated and deserves careful attention. Several problems come to mind immediately:

1. Determining what is best practice over time is problematic in general medicine, and often enough what is called best practice now later falls out of favor or is replaced by a ‘new’ procedure. Journal of Medicine Association (JAMA) is a good source for this issue, but I do not have a subscription. This blog is worth a read.

2. Best practice is established and arbitrated in a variety of ways. A policy goal might be to help develop best practice and establish baseline quality as in the UK.

3. Chronic conditions such as diabetes versus acute conditions such as heart surgery or use of stents plays an important role in how we allocate resources. Innovation is rewarded in particular ways that impact care and our health.

4. Efficiency is gained in various ways, some negative and some positive, but to date costs are huge.

5. Profit margins defines what is a medical problem and what is not in the form of research and insurance payment schedules. Maximizing % of profit margin appears to predominate as opposed to more marginal gains that might have better overall outcomes over time.

Incentives to treat soldiers are a huge issue:

Regulars know that I prefer starting with an example before I get to aggregates or huge policy issues. This one is dear to all our hearts I am sure. While this is specifically stated as a government oriented problem using Tricare insurance for military, retirees, families and others, it is not specific to government functions because private insurers are only marginally better in this arena.

EMDR is one of the most researched interventions round the world for PTSD and in particular combat PTSD. This best practice guideline recommending CBT and EMDR, published in March 2005 by the UK ’s National Institute for Clinical Excellence names it specifically as one of treatment of choice. Good general information is here.

The VA system approves its use finally at a late date in the research as one of four preferred treatments. Psychopharmacology is a resource mentioned. AMA, APA, NASW approve its use.

At EMDRIA’s (organization advocating the use of this method) request in 2005, TRICARE did a review of EMDR for the treatment of PTSD and concluded that the treatment was “unproven”. In April 2006, TRICARE agreed to do a “more in-depth review, but in an August 31, 2006 policy document TRICARE said that “EMDR is not psychotherapy”. The credential as regards innovation in our health system is for another post, but thought some might want to check the issue with their own sources (so I mention it here) since military in particular will be of interest to several readers.
With credential established, I find this interesting:
Soldiers returning from war are finding it more difficult to get mental health treatment because military insurance is cutting payments to therapists, on top of already low reimbursement rates and a tangle of red tape.

Wait lists now extend for months to see a military doctor and it can takes weeks to find a private therapist willing to take on members of the military. The challenge appears great in rural areas, where many National Guard and Reserve troops and their families live. To avoid the hassles of Tricare, the military health insurance program, one frustrated therapist opted to provide an hour of therapy time a week to
Iraq and Afghanistan veterans for free. Barbara Romberg, a clinical psychologist in the Washington, D.C., area, has started a group that encourages other therapists to do the same.
Instead of quoting from an article, from personal knowledge the problem goes like this:

A psychologist or clinical social worker becomes specially trained and licensed for either treatment modality. Market rate without insurance in this area is pegged at $125-150/session. Insurance payment is a percentage of this market rate, or set at $89.50/hr./session for Blue Cross/Blue Shield of MA, and Tricare will pay a maximum of about $79 hr./session. The billing is done on face-to-face time, so the costs of billing and quality controls are included in this charge, with frequent attendant problems regarding billing procedures and changing quality control criterion. It is a significant cost factor in all insurance and more so in Tricare. Many therapists in this area do not accept this insurance, and many are not accepting any insurance as private practitioners. Remember most private practitioners pay their own health insurance costs (about $12,000/year family), rent, etc.

There are several problems involved, and I do not see either government or private health care dealing with it adequately. What are the incentives for a hospital (where conditions also are becoming much harsher in this area) or private practitioner to provide this service as a normal part of care? Is it important, and how should we respond?