Anybody else dislike the Fetterman coverage?

[birchswing]

I've disliked it for many reasons.

There is this running narrative in the media and general do-gooders that Fetterman is setting a great example for middle aged men who have too much machismo to seek help.

From my point of view you would need to have incredible strength to enter a psychiatric facility, not because of stigma but because they are traumatizing. I bet he's getting first class care compared to most. The facility in my town has Google reviews that would make you prefer to go to prison (in fact one of the reviewers has been to both and said that prison was better and less dangerous). I'd post a link but I don't want to dox myself too much. I'm sure there are ones that aren't that bad, but I think you probably have to be well connected to get humanistic care. To me I view psychiatric facilities as being traumatizing (i've never been to one myself, but I've been discouraged from going for that reason), and yet there is this narrative in the media that Fetterman is setting an example of overcoming that stubborn male ego that would prevent someone from receiving humanistic help. From what I've read there is not much humanistic about a stint in a psychiatric hospital. I have a feeling, though, he is receiving much better care than the 99% of people the media is nagging about being too stubborn.

Then there was the Huffington Post article where they quoted a doctor saying there should be no stigma because "our brain is just another part of our body."

The nervous system is one of the first parts of the body to develop in gestation. (As an aside, can someone tell me what the term for that is? I learned that in developmental psychology, but I can't remember the term for organisms that grow from the nervous system outward.) Everything else in the body is in service of the brain and vice versa. It's not "just another body part." There are no other organs with such specialized centers as the brain that have such vastly differentiated functions as the brain has. Everything in the liver, for example, works in tandem. The brain does not work that way. It has very highly specialized centers and neuron types, like multiple computers. The brain is not a monolith.

Fetterman's stroke itself perfectly demonstrates the differentiation: the loss of part of a single domain (language) but not others such as motor control, smell, etc, etc.

It's disingenuous to suggest a drug will just go in and like a heart med will selectively target cardiac beta receptors for example. Psych drugs are not that selective. They are not at this point capable of treating the brain like any other body part and probably never will because the brain isn't like any other body part.

I see all these publicly telegraphed messages to him about how he'll be back to his old self in no time (not referring to the stroke), etc., from very prominent politicians, and I understand depression can be limited to several weeks in certain cases, but I think they are being very reductivist about this situation and making it sound like there is some panacea for mental health issues that other people are avoiding out of stubborness.

I'm not sure if it's ignorance or wishing things were different, but it's out of touch with the realities and limitations of treatment for mental healthcare. There is no cure for Fetterman, but even less so for people without his level of access.

I am not even sure that the average person could even voluntarily check themselves into a hospital for depression—I am suspicious of that, but perhaps you all can comment. Maybe the full story isn't being told, but the story that has been told was that he voluntarily checked himself in for depression. I've generally been told the bar is much higher—as in imminent risk to yourself or others, disorganized thinking, unable to care for yourself, etc.

I'm mainly tired of the media hectoring everyone saying what a great example this is, as if we're all just too stubborn to get first-class care at Walter Reed from likely some of the best physicians in the country. It's just like when Trump was airlifted to Walter Reed and acted like Covid was nothing when he too got treatment 99% of people wouldn't have gotten and said he felt amazing (I think because he was hopped up on steroids). I think these politicians and the media are out of touch or are just trying to say the right thing. My impression is the average person is not going to get admitted to begin with, if they are it's not going to be pleasant, and I don't think they do in fact just go back to being themselves. It's a lot of whitewashing to destigmatize mental health, when I don't think stigma is the main problem with mental illness and mental healthcare. I think the problems are societal, I think mental illness is very complex, I think there are lacking safety nets, and I think mental healthcare is in its infancy, but it's talked about like it's just like any other disease and like psychiatric facilities are like any other hospital stay.

If the alternative was that he was going to die of suicide and this is keeping him safe for now while stabilizing him on medications, then yes, that's a good story. But that's not the story they're telling.

They should tell the truth about what the purposes of a psychiatric hospitalization are, what is possible and not possible, what the problems are with the qualities and traumas of inpatient hospitalization, and the enormous costs. If they said something like, "This is a good option if you're at risk of dying," I feel that would be much more honest.

Either he is getting inpatient help for a condition I don't believe most people could, or his situation is different than what has been implied. Either way the media is selling it as a story for more people to get help for depression in general and that they haven't due to stubbornness.

I've said before in this forum I think there should be reform of the facilities and people should have beds in the same hospitals where people receive other healthcare, but I remember someone responded to me when I said that saying the goal was to not make people too comfortable so that they'll leave. I know the facility in my town does not have enough oversight, and I would personally never go to that facility in particular and would also avoid them in general—and I do not suffer with stubbornness against asking for help or machismo.

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[Sushirolls]

... My impression is the average person is not going to get admitted to begin with, if they are it's not going to be pleasant, and I don't think they do in fact just go back to being themselves. ...

The assumptions are just wrong, false, whatever negative label you want to assign.

There are positives and negatives to units that attached to hospitals and those that are free standing separate from hospitals. Quality isn't predetermined by location. Quality is determined by the Big Box running it, and the staff they hire, and how those two intersect within the confines of insurance. That's it. There is no secret or conspiracy theory or any other nuance behind the scenes. It really is that simple. These are not mystical facilities.

Their goal is stabilize and/or reduce the acuity of a person's symptoms. That doesn't mean cure. That doesn't mean fix. That means good enough to facilitate discharge.

A key focus to psychiatry is lowest level of care. Which means people get discharged as soon as reasonably possible to facilitate lowest level of care. Imperfect symptoms, imperfect Big Box shop admin, imperfect staff definitely leave room for improvement.

I wouldn't hesitate to recommend my own family to get admitted if needed.

*My barber is imperfect. The wait, the chair quality, the topic of conversation at the shop, the high price, the hours of service. But I still go when its needed, because the times I've done my own... people give me an earful.
*Same thing for my mechanic. They'll get me in days later after what I want, but that's my only option. The price is too much, phone service is questionable, things break again as soon as I leave the lot. But they ultimately are putting forth a reasonable effort to fix my vehicle within the confines of their ability to diagnosis, and get aftermarket parts and make them all fit with the existing worn parts. They are striving for good enough, and that's what I need, even if not what I want.

 

[Sushirolls]

Trump, Fetterman, Feinstein, Biden, Hillary, whomever... pick one.

All are fair game for any commentary about whatever the political hit point is for the week.
Once people cross into public service they don't get the decorum of decency extended to normal folks.

For instance, if Fetterman isn't doing the job he was elected for... he needs to be removed or resign. No different than if he was selling secrets to the Chinese, taking bribes, whatever. He represents, as a vote, the voice of ~13 million people. His failings to discharge his duty means ~13 million people are silenced. That is not something trivial.

If Fetterman is my senator, and I a Pennsylvanian, I will have already written his office requesting he step down. I want my representation, and if my politician can't do that, they need to fix themselves in prison, the hospital, spiritual walkabout, time with family, whatever; but on their time, not on my tax payer funded elected official time.

But to your original post about disliking the nature of politician coverage, I'm always disappointed. My politicians never get enough good press, and those that don't hold my views never get enough bad press...

 

[birchswing]

These are not mystical facilities.

You don't think the singular facility that serves US presidents probably has a higher level of care and oversight?

I think I am spooked by the one in our town (the psychiatrists and therapists I've spoken to also seem spooked by it) in particular so I probably have a slanted view.

But would you not say there's more heterogeneity among psychiatric facilities than your basic bread and butter hospital that a person might enter for a heart, kidney, etc issue? I don't hear of people going in for MIs and having traumatizing experiences because of the staff/other patients/inability for family members to get updates like I do with some psychiatric facilities—maybe for the original condition but not the other factors. I haven't seen a review for a non-psychiatric facility that says "I wouldn't send my worst enemy here" and where people seem to be afraid for their physical health (many of the complaints for the one in my town were for having non-psychiatric medical emergencies while in the psychiatric facility that were not addressed).

Trump, Fetterman, Feinstein, Biden, Hillary, whomever... pick one.

All are fair game for any commentary about whatever the political hit point is for the week.
Once people cross into public service they don't get the decorum of decency extended to normal folks.

For instance, if Fetterman isn't doing the job he was elected for... he needs to be removed or resign. No different than if he was selling secrets to the Chinese, taking bribes, whatever. He represents, as a vote, the voice of ~13 million people. His failings to discharge his duty means ~13 million people are silenced. That is not something trivial.

If Fetterman is my senator, and I a Pennsylvanian, I will have already written his office requesting he step down. I want my representation, and if my politician can't do that, they need to fix themselves in prison, the hospital, spiritual walkabout, time with family, whatever; but on their time, not on my tax payer funded elected official time.

But to your original post about disliking the nature of politician coverage, I'm always disappointed. My politicians never get enough good press, and those that don't hold my views never get enough bad press...

I haven't seen Republicans taking the bait asking him to step down—and it's wise of them not to. It's people who share my own political leanings I'm upset with for painting an idyllic picture. In fairness to Fetterman, Pennsylvania's *other* senator is also currently hospitalized after prostate cancer surgery and will be out for several weeks. Would you say that is different than being hospitalized for depression? In that case, I can see the stigma argument. But I haven't heard people calling on Fetterman to step down. I've only seen the preemptive arguments defending Fetterman and in doing so I think making some clumsy over-simplified statements about depression and why other people don't seek care. I think it's more likely Democrats would eventually have to ask him to step down if he's not available as a vote, and then Pennsylvania would call a special election. Him not being available for floor votes isn't such a big deal with the balance of power, but it does mess up Democrats' ability to get things done in committee, so him being incapacitated is right now a bit of a win for Republicans, which is maybe why you don't see calls for him to step down—I think that will come from Democrats if he can't return soon enough.

 

[splik]

I couldnt disagree more. It is rare for people to disclose a history of mental illness and hospitalization and what we’re seeing here is even people like Ted Cruz being supportive. It shows how far things have come in some respect in terms of stigma of non psychotic illness.

If you have commercial insurance yes you can check yourself in voluntarily to an inpatient unit that accepts voluntary patients. These units are often nicer and the acuity of patients lower and thus less scary or traumatizing to use your word. I usually have my own patients admitted voluntarily where possible. It’s usually pts on Medicaid who can’t check in voluntarily but that’s not true across the board. Medicare pts can also check in voluntarily.

Psychiatric hospitalization can certainly be traumatic but so can medical hospitalizations. Both can involve coercion and use of restraints and forced medication but there is usually more oversight and due process during psychiatric hospitalization than medical hospitalization. Patients can be assaulted in both psych and general medical settings. Sexual assaults can happen in both settings. Patients with critical illness in an ICU setting are vastly more likely to develop PTSD than pts on a psychiatric unit.

Of course fetterman is able to access a level of care many people aren’t but of that group of people that could many would not snd the majority would be unlikely to publicly disclose it. I don’t see any media coverage lamenting Joe Schmo not seeking care but people in positions of import or high visibility doing so.

Psychiatric hospitalization is not a benign intervention and access to care is unequal. That does not detract from the significance of a freshman senator disclosing in real time his psychiatric hospitalization and the generally positive response. No one is complaining that “male stubbornness” is a thing but it is a fact that men are reticent to seek mental healthcare because it is seen as a weakness. It is a positive that the script has been flipped and it is now being seen as a strength to do so.

 

[birchswing]

I couldnt disagree more. It is rare for people to disclose a history of mental illness and hospitalization and what we’re seeing here is even people like Ted Cruz being supportive. It shows how far things have come in some respect in terms of stigma of non psychotic illness.

If you have commercial insurance yes you can check yourself in voluntarily to an inpatient unit that accepts voluntary patients. These units are often nicer and the acuity of patients lower and thus less scary or traumatizing to use your word. I usually have my own patients admitted voluntarily where possible. It’s usually pts on Medicaid who can’t check in voluntarily but that’s not true across the board. Medicare pts can also check in voluntarily.

Psychiatric hospitalization can certainly be traumatic but so can medical hospitalizations. Both can involve coercion and use of restraints and forced medication but there is usually more oversight and due process during psychiatric hospitalization than medical hospitalization. Patients can be assaulted in both psych and general medical settings. Sexual assaults can happen in both settings. Patients with critical illness in an ICU setting are vastly more likely to develop PTSD than pts on a psychiatric unit.

Of course fetterman is able to access a level of care many people aren’t but of that group of people that could many would not snd the majority would be unlikely to publicly disclose it. I don’t see any media coverage lamenting Joe Schmo not seeking care but people in positions of import or high visibility doing so.

Psychiatric hospitalization is not a benign intervention and access to care is unequal. That does not detract from the significance of a freshman senator disclosing in real time his psychiatric hospitalization and the generally positive response. No one is complaining that “male stubbornness” is a thing but it is a fact that men are reticent to seek mental healthcare because it is seen as a weakness. It is a positive that the script has been flipped and it is now being seen as a strength to do so.

I can take your disagreements, but what about these facile arguments in the media that the brain is like any other part of the body? Is it necessary to lie about mental illness in order to destigmatize receiving treatment? Analogously, I was an ardent and vocal supporter of marriage equality, yet I vehemently disagreed with the notion that kept being put out that people were born gay as an argument for marriage equality. That was a constant drumbeat, and it was unknowable. And it seemed completely unnecessary to make the argument to give people their rights under the law. The conceptualization of being gay didn't even exist until recently, so the idea of it existing at birth before a person had been socially conditioned into understanding concepts like gay or straight never made sense to me. Of course there are biological differences, the most prominent theory having to do with exposure to testosterone antibodies in the womb, but the ways in which they manifest are going to vary drastically between time periods and cultures and prevailing social concepts that those biological differences can fit into. I see the media doing the same thing with mental illness. What difference does it make if the brain is just like a heart (which of course it isn't), let alone assuming that mental illness only concerns the state of the brain. People deserve compassionate care either way. They don't need to lie.

As far as trauma in a "regular" hospital vs a psychiatric facility, maybe I've just been spooked, but I've heard horror stories. I've had two overnight stays in a "regular" hospital for lack of a better term, once for an appendectomy and once for refractory SVT, and it was like an upscale hotel. I had my own room, my own bathroom, meal service. It was lovely and clean. My movements were not restricted in any way (well I guess you could argue the time I was under anesthesia for the surgery I was restricted, but I voluntarily had surgery). Yet when I've discussed with therapist and psychiatrists and a social worekr the possibility of inpatient care before in a psychiatric facility they've told me it would be traumatizing and not something I would do well experiencing, and everything I've read about the local facility (which I don't think is technically a hospital) bears that out. It's been in the local news. They had a rape. There's been at least one death I know of resulting from lack of medical care, in which another patient tried to get the patient help using a payphone and calling 911. It just sounds like you'd have to be insane to go there. I always think to write up but never have a living will that I'd refuse to get care there.

I don't think I'm crazy in this. This is something I hear repeatedly. If I ever brought up hospitlizaiton the response was very solemn, "No . . . you don't want to do that." Not like, no it wouldn't be helpful. Not like, six of one half a dozen of another. Very much like: This would be bad.

Just a quick search for my state (I won't dox my city but I'll give away that I'm in Virginia):

Starting in 1990, the Justice Department began a multi-year investigation of Virginia’s mental hospitals for what it described as patient care so inadequate that it created dangerous and even life-threatening conditions. In the latter part of that decade, my friend and Associated Press colleague Bill Baskervill embarked on groundbreaking reporting that documented ghastly, almost medieval practices at understaffed, poorly managed and poorly overseen state hospitals.

Baskervill, long since retired, worked in AP’s Richmond bureau and won national accolades for his dogged investigative reporting into horrifying treatment of patients at state-run mental hospitals. Among his findings were accounts of patients who lay on their backs, bound hand and foot with heavy leather restraints for days on end; of a woman who died in such conditions after her complaints and warnings from family members that she was dying went unheeded; of allegations by the father of a 19-year-old who said his son was so savagely sodomized by staff at one hospital with an object similar to a broom handle that it tore his bowel, punctured his liver, sending him into a coma and, 14 months later, his death.

Decades, tragedies and heartaches later, Virginia’s mental health system still struggles • Virginia Mercury

Despite decades, tragedies and studies, Virginia's mental health system remains broken.

www.virginiamercury.com

I mean you're saying bad stuff happens at all hospitals: But being raped to death? Does anyone actually worry about that in a "regular" hospital?

There is a state facility in my town, but I don't even think that has a waiting list anymore. But the private facility I'm thinking of is very small, and it is known for horrible things like what are described with the state hospitals.

 

[splik]

I mean you're saying bad stuff happens at all hospitals: But being raped to death? Does anyone actually worry about that in a "regular" hospital?

There is a state facility in my town, but I don't even think that has a waiting list anymore. But the private facility I'm thinking of is very small, and it is known for horrible things like what are described with the state hospitals.

Sorry, that is not something most people worry about happening in any hospital. These kinds of things are extremely rare.
That said, I used to work at one general hospital (that was highly regarded). Some years ago one of the surgical residents was allegedly drugging patients and raping them on the surgical wards.

As for your other arguments. I don't think the media is deliberately trying to mislead people but complex topics have to be reduced to digestible soundbites for people with a 4th grade reading level. Personally, I think it is quite irrelevant whether the brain is more complex than other organs to any discussion of whether we should reduce the stigma of mental illness. Ironically, your own arguments seem to be based on highly stigmatized and inaccurate or outmoded views of psychiatric hospitals and wards. Some are certainly grim (and state hospitals which is what you're drawing on in your own post are often old asylums and care for institutionalized patients are often the grimmest of psychiatric facilities) and there is a long history of abuses against psychiatric patients but may facilities provide a decent level of care that is much needed. The local psychiatric hospital or ward is a far cry from a state hospital.

It could be that the facilities available to you are not good. From my understanding Virignia does have a massive shortage of psychiatric beds. That means there there is probably a very high acuity in those units/facilities and a focus on psychotic patients. Those more acute facilities can certainly be scary for people with less severe, non-psychotic illness. In an ideal world, everyone would have access to psychiatric units with patients with a similar level of need/problem (e.g. psychotic patients on one unit, mood disorder pts on another, personality disorder patients on another) but as beds have closed the length of stay has decreased and the acuity of units has increased with patients often mixed together. In my area, I certainly wouldn't want my patients going to the county hospitals, but there are at least 5 hospitals in the area that I would be happy for my patients to seek voluntary psychiatric admission. Given the dearth of psychiatrists, and psychiatric beds, this is certainly not the case everywhere.

 

[Desired Member]

…I see all these publicly telegraphed messages to him about how he'll be back to his old self in no time (not referring to the stroke), etc., from very prominent politicians, and I understand depression can be limited to several weeks in certain cases, but I think they are being very reductivist about this situation and making it sound like there is some panacea for mental health issues that other people are avoiding out of stubborness.

I agree with this specific part of your post! Same thing bothered me

If the alternative was that he was going to die of suicide and this is keeping him safe for now while stabilizing him on medications, then yes, that's a good story. But that's not the story they're telling.

I read in a news article that his outpatient doctor recommended that he go to inpatient psych. Usually this means that the person is severely ill (SI , HI, psychosis , and/ or severe negative symptoms/catatonia).

 

[birchswing]

I read in a news article that his outpatient doctor recommended that he go to inpatient psych. Usually this means that the person is severely ill (SI , HI, psychosis , and/ or severe negative symptoms/catatonia).

Yes, that's sort of the conclusion I came to as I was writing my post. My cursory take seeing the headlines was this is someone with depression who is getting higher level of care that most people wouldn't, and it seemed silly they were using as an outreach message for others to get similar care. I thought it was a bit elitist. But as I wrote I started to answer my own questions. Maybe I'm a bit dense and other people intuited hospitalization meant more serious issues—which I only realized by pontificating and writing about it. I guess if they can't state the specifics more explicitly there still is a stigma. On the other hand, there are a lot of things like that with politicians. Trump got checked in to the same hospital out of what they said was an abundance of caution for Covid, and it turned out after the fact he was gravely ill. And there's Kamala Harris who took Paxlovid for a Covid infection they claimed was asymptomatic, which stumped a lot of people. So I guess it's not just psych. Just reading the headlines, my own biases before I considered the matter at length thinking it was elite care for the well connected and that most people don't go into a hospital like that for depression (without qualifying it such as you did with SI/HI, psychosis, etc.).

Even if I am a bit dense, I doubt I can be the only one, and I feel like this story does sow confusion in people about the spectrum of depression and when a person would check into a hospital. The type of qualification you gave I think is the type that could be helpful in news stories rather than making this a general PSA for people with depression about not being afraid to seek help.

 

[TexasPhysician]

I’ll keep my points simple:

I’m not sure the media ever displays an event objectively. There is always an angle with inaccuracies. With a constant push for ratings/viewers, the news can be more dramatic than reality tv.

Talking about mental illness is almost always a good thing. Let’s say your spouse has MDD and needs to be hospitalized vs needing inpatient medical for a heart, kidney, thyroid, or other issue. I’d argue that most would be honest with neighbors, friends, and family about what is happening about the other organ issues. You may even talk to religious peers about needing prayers. Would you be honest about inpatient psych? Most wouldn’t.

Knowing that the media always has an angle, I’m just pleased that we are talking about mental illness in a way that doesn’t further the stigma that this person is flawed and broken forever.

 

[calvnandhobbs68]

If Fetterman is my senator, and I a Pennsylvanian, I will have already written his office requesting he step down. I want my representation, and if my politician can't do that, they need to fix themselves in prison, the hospital, spiritual walkabout, time with family, whatever; but on their time, not on my tax payer funded elected official time.

So no representative or senator can every be hospitalized for anything ever because they're sick on your "taxpayer funded elected official time"? This is such a ridiculous view it's hard to even rationalize it. There are plenty of examples of senators having to be hospitalied for stuff and not having to step down. How many times was John McCain hospitalized over the course of his career....

State Sen. André Jacque Released From Hospital After Being On Ventilator With COVID-19

Wisconsin state Sen. André Jacque has been released from the hospital more than three weeks after being placed on a ventilator because of a COVID-19 infection. Jacque, a Republican from […]

www.wpr.org

I can randomly google search in 20 seconds and find out this dude was on a vent for 3 weeks in 2021 and nobody seemed to give much of a crap.

How did I know this thread was gonna go this way once old Sushi got involved....

 

[birchswing]

One other thing came to mind regarding my egalitarianism points: This would be a perfect opportunity to talk not just about depression but paid leave.

I was questioning whether others could simply go inpatient for depression at all, let alone in a humanistic, safe facility like Fetterman—and there seems to be some debate on that, and perhaps I am wrong on some accounts (although above I pushed back on others). But paid leave is really the economic justice issue that should be the clarion call that emerges any time a public representative can take care of themselves regardless of the medical issue.

I am reminded of so many people in the service industry who cannot take paid leave like Fetterman can. They could theoretically take FMLA, but that remains theoretical for most people as they need the income. I've taken a deep dive into a lot of the subreddits for various service industry companies like Walmart, Home Depot, etc., and managers are not letting employees even take unpaid time off with fevers of 102 for both Covid and Covid-like viruses (not sure what the viruses are but a lot of people seem to lately be posting they have Covid type symptoms and testing negative). Either way, it seems like a lot of people are going to work sick or face losing their jobs. I hope it's clear, I think that's terrible.

Whatever my hang-ups with the messaging on depression and hospitalization, the Fetterman camp (and any politician who has to take leave) could put out public messaging about needing to extend the good fortune they have as salaried employees able to take leave to everyone, salaried or hourly, regarding paid leave.

Just to double check what I assumed (that there are no limits on sick days for senators) this was the top search result:

Senators with unlimited sick days vote down paid leave for railway workers

Though the measure ultimately failed, it did receive some bipartisan support.

www.newsweek.com

That is messaging I would take to, and I personally think is more relevant to the lives of most people than destigmatizing depression. It doesn't have to be a competition among causes, but when I wrote above that I think mental illness is more complex than how it's made out (the doctor in HuffPo essentially describing a mentally ill brain as a broken down car) I said there are societal forces and lack of safety nets at play in mental illness, and certainly a lack of paid leave and squeezing workers more and more is part of that.

So no representative or senator can every be hospitalized for anything ever because they're sick on your "taxpayer funded elected official time"? This is such a ridiculous view it's hard to even rationalize it. There are plenty of examples of senators having to be hospitalied for stuff and not having to step down. How many times was John McCain hospitalized over the course of his career....

State Sen. André Jacque Released From Hospital After Being On Ventilator With COVID-19

Wisconsin state Sen. André Jacque has been released from the hospital more than three weeks after being placed on a ventilator because of a COVID-19 infection. Jacque, a Republican from […]

www.wpr.org

I can randomly google search in 20 seconds and find out this dude was on a vent for 3 weeks in 2021 and nobody seemed to give much of a crap.

How did I know this thread was gonna go this way once old Sushi got involved....

I agree, and as I said above, *both* of Pennsylvania's senators are currently on leave for health problems—the other for recovery after prostate cancer surgery. So there really is a direct comparison to be made. You can't fault Fetterman without faulting Bob Casey.

 

[clausewitz2]

I agree with the sentiment that this represents a real sea change in public perceptions of mental illness in politicians, at the very least. It is not quite 50 years ago that George McGovern's presidential campaign got torpedoed (at least in part) based on the fact that this running mate had received inpatient treatment for depression. We have come a long way.

 

[G Sheb]

The crux of the trauma from psychiatric hospitalization is the involuntary status. Though I think psych ERs can be even more traumatizing than inpatient units.
Even then, unless it's a particularly violent unit or there are poor hygienic standards (maybe this is really just my concern lol) it's really not that 'traumatic'.
It is absolutely important that people come forward and are able to get the care they need. There's still so much stigma around mental illness, despite the leaps we're making.

 

[G Sheb]

Whatever my hang-ups with the messaging on depression and hospitalization, the Fetterman camp (and any politician who has to take leave) could put out public messaging about needing to extend the good fortune they have as salaried employees able to take leave to everyone, salaried or hourly, regarding paid leave.

Just to double check what I assumed (that there are no limits on sick days for senators) this was the top search result:

This is absolutely true. We should be talking about this as well.
The stuff that employers can get away with in this country is absolutely horrifying. Child labor, making people work for sometimes 2 weeks without a day off, no health insurance, in some cases no minimum wage (restaurant industry) is scandalous. It's time we fix this.

 

[Sushirolls]

So no representative or senator can every be hospitalized for anything ever because they're sick on your "taxpayer funded elected official time"? This is such a ridiculous view it's hard to even rationalize it. There are plenty of examples of senators having to be hospitalied for stuff and not having to step down. How many times was John McCain hospitalized over the course of his career....

I can randomly google search in 20 seconds and find out this dude was on a vent for 3 weeks in 2021 and nobody seemed to give much of a crap.

How did I know this thread was gonna go this way once old Sushi got involved....

Time limited illnesses of short duration. Sure, things happen, people recover and get back to work.

Fetterman already wasn't fit for office to begin with. Now throw on top depression in context of post stroke - assuming its just depression - and nothing else his PR team is concealing. Odds are, this isn't something that's going to remit quick and get back to his already unfit for office baseline. We've all seen the different types of stroke recoveries; and a key to most of them is doing the recovery. Working with PT/OT, PM&R, whomever. Managing the depression that is oft to pop up at some point. Its a long road to recovery; but to throw on top of it the demanding job of being a senator? That's a recipe for disaster from the start. He and is wife should have pulled out during the campaign. It's one thing for society to be supportive and trying encourage people to function as best as possible. Am I saying other politicians should step down if depressed? No. Depression like PNA or Cholecystectomy or Covid, people will bounce back recover and get to doing their job again - no big deal. Now if a politician has Bipolar I, intentionally isn't taking their meds, and continually has symptoms? No, they should step down. Stable on meds? Keep on being a politician, kudos.

But its sad and tragic when we do the opposite and push people too far for the demands of a political position, essentially sacrificing them for the benefit of a political party. There are at least 2 politicians with dementia in office, and then there is Fetterman. This isn't disability advocacy to be applauding and excited for this is just sad, shameful abuse of some ones family member / loved one.

Your other example of a 3 week covid, that's time limiting, single event, not a big deal, to your point, yes people get sick and need to bounce back.

 

[Sushirolls]

This is absolutely true. We should be talking about this as well.
The stuff that employers can get away with in this country is absolutely horrifying. Child labor, making people work for sometimes 2 weeks without a day off, no health insurance, in some cases no minimum wage (restaurant industry) is scandalous. It's time we fix this.

No. We don't need to fix anything. People are not victims, they are not being enslaved.
Obacamare / exchanges. People just need to adult and get on an insurance that is subsidized. Very doable.
People working 2 weeks straight have the choice to choose a different job.
You can't throw a stick in a main street - big or little towns - without hitting a sign right now that says "we are hiring."
Don't like the structure of pay in relation to restaurants and tips? Then don't do a server job, be a cook, or get a different job.
Child labor, what in the US? This is not some broad spectrum issues. We have the opposite problem. Be a parent with a 15yo, and try to encourage your child to get a job. This age group because of rules and bureacracy is essentially squeezed out of the labor market. This further compounds things like the other thread of kids not growing up but being stagnated couch dwellers at their parents.

 

[whopper]

I like Fetterman, but this isn't liking or disliking.

This is about someone in a position of high power where physical and mental health need to be stable to expect good results.

Anyone, whether they GOP, DNC, L or R or whatever, this is information the public should be allowed to have to make their own minds at the voting booth.

Now all this said lots of idiots will twist this for or against, the media will add to the BS.

 

[calvnandhobbs68]

Time limited illnesses of short duration. Sure, things happen, people recover and get back to work.

Fetterman already wasn't fit for office to begin with. Now throw on top depression in context of post stroke - assuming its just depression - and nothing else his PR team is concealing. Odds are, this isn't something that's going to remit quick and get back to his already unfit for office baseline. We've all seen the different types of stroke recoveries; and a key to most of them is doing the recovery. Working with PT/OT, PM&R, whomever. Managing the depression that is oft to pop up at some point. Its a long road to recovery; but to throw on top of it the demanding job of being a senator? That's a recipe for disaster from the start. He and is wife should have pulled out during the campaign. It's one thing for society to be supportive and trying encourage people to function as best as possible. Am I saying other politicians should step down if depressed? No. Depression like PNA or Cholecystectomy or Covid, people will bounce back recover and get to doing their job again - no big deal. Now if a politician has Bipolar I, intentionally isn't taking their meds, and continually has symptoms? No, they should step down. Stable on meds? Keep on being a politician, kudos.

But its sad and tragic when we do the opposite and push people too far for the demands of a political position, essentially sacrificing them for the benefit of a political party. There are at least 2 politicians with dementia in office, and then there is Fetterman. This isn't disability advocacy to be applauding and excited for this is just sad, shameful abuse of some ones family member / loved one.

Your other example of a 3 week covid, that's time limiting, single event, not a big deal, to your point, yes people get sick and need to bounce back.

sure I agree people need to have decent cognitive capacity to be in national office for sure. I've always said they should be doing biannual neuropsych testing on all the senators, president and vice president. Which included Biden, Trump, Pelosi, McConnell, Schumer, etc. There's certainly the resources for it and we certainly spend tax money on much dumber stuff.

 

[Merovinge]

sure I agree people need to have decent cognitive capacity to be in national office for sure. I've always said they should be doing biannual neuropsych testing on all the senators, president and vice president. Which included Biden, Trump, Pelosi, McConnell, Schumer, etc. There's certainly the resources for it and we certainly spend tax money on much dumber stuff.

Biannual sounds like hyperbole, but I would at least consider a world where running for office required a combine-type experience for the applicants. Would be really helpful to post an actual fact-checked CV, maybe get neuropsych testing results, answer some simulated questions that are standardized (like an OSCE or cone drill as it were). I am sure someone who cares more about politics could devise something that would actually be helpful to the voting public.

 

[G Sheb]

No. We don't need to fix anything. People are not victims, they are not being enslaved.
Obacamare / exchanges. People just need to adult and get on an insurance that is subsidized. Very doable.
People working 2 weeks straight have the choice to choose a different job.
You can't throw a stick in a main street - big or little towns - without hitting a sign right now that says "we are hiring."
Don't like the structure of pay in relation to restaurants and tips? Then don't do a server job, be a cook, or get a different job.
Child labor, what in the US? This is not some broad spectrum issues. We have the opposite problem. Be a parent with a 15yo, and try to encourage your child to get a job. This age group because of rules and bureacracy is essentially squeezed out of the labor market. This further compounds things like the other thread of kids not growing up but being stagnated couch dwellers at their parents.

A 15 year old should be studying and living their childhood before it will soon be done with.
You have individuals whose net worth is bigger than the GDP of a dozen countries put together, but god forbid someone is paid a decent wage or gets a day of rest in a week.
Wow. You come across as incredibly crass given how much you complain about 'big box shops'.

 

[clausewitz2]

Biannual sounds like hyperbole, but I would at least consider a world where running for office required a combine-type experience for the applicants. Would be really helpful to post an actual fact-checked CV, maybe get neuropsych testing results, answer some simulated questions that are standardized (like an OSCE or cone drill as it were). I am sure someone who cares more about politics could devise something that would actually be helpful to the voting public.

I mean, there is at least one major country that has competitive elections and where there is definitely a rigorous system in place to certify that candidates are fit for office along strict criteria.

That place is the Islamic Republic of Iran.

A system where a group of officials exercise their expert judgement on whether someone can be an electoral candidate and that person is barred from running if they don't make it rapidly becomes an instrument by which whoever holds power steps all over their opponents.

 

[Sushirolls]

A 15 year old should be studying and living their childhood before it will soon be done with.
You have individuals whose net worth is bigger than the GDP of a dozen countries put together, but god forbid someone is paid a decent wage or gets a day of rest in a week.
Wow. You come across as incredibly crass given how much you complain about 'big box shops'.

A job for a 15yo can be just as educational as moonlighting is to a resident.

I have an employee. And when I had a Sleep Medicine physician subleasing from me, also helped that practice navigate hiring of employees and Payroll etc.

The entitlement push by the left to think employers must 'pay a decent wage' is ludicrous. The more laws, the more mandates, the more the government pushes for "more" from businesses, the greater the burden on employers especially small time employers like myself. It makes it so we can't compete and can't survive. It only serves to help Big Box employers. All this and how it relates just to small employer private practice's really could be its own thread.

What you call crass, I call American. No its not an employers duty, nor obligation to "pay a decent wage." These sentiments hurt smaller entities far more than larger entities.

 

[FutureInternist]

This is absolutely true. We should be talking about this as well.
The stuff that employers can get away with in this country is absolutely horrifying. Child labor, making people work for sometimes 2 weeks without a day off, no health insurance, in some cases no minimum wage (restaurant industry) is scandalous. It's time we fix this.

One party tries to do these things, albeit not to a level that I would like, while the other not only says No, but actively does the opposite in removing protections, allowing minors to be hired, fighting against paid leave, parental leave, sick leave, unionisation etc etc etc…. All while giving corporations more & more tax breaks and bringing the social safety nets to a halt….so they can then say “See, we told you gov can’t do it, so let’s privatize it”, and hence further enriching their donors and further harming those who need help the most.

 

[Merovinge]

I mean, there is at least one major country that has competitive elections and where there is definitely a rigorous system in place to certify that candidates are fit for office along strict criteria.

That place is the Islamic Republic of Iran.

A system where a group of officials exercise their expert judgement on whether someone can be an electoral candidate and that person is barred from running if they don't make it rapidly becomes an instrument by which whoever holds power steps all over their opponents.

That's not even close to what I was saying, there would be no cut-offs or minimums, just transparent results. I'm talking about an event like the football combine where the results of performance on each test is standardized and made public. You can run a 6 second 40 yard dash and not be excluded, it would just be the information made public (and obviously this is not the actual event I would propose for public office but as way of analogy). If people want to elect an official with a FSIQ of 65 because they follow the same ethos to them, they should be allowed to do so, but it sure would be nice to know a person's credentials if we want anything resembling a meritocracy rather than whatever system the US has right now.

 

[birchswing]

This coverage and opinion piece on many Americans not having the level of access as Fetterman I thought was much better than the talk about battling stigma:

Opinion: What Does John Fetterman's Mental Health Say About America

While the Pennsylvania senator has been open about his recent depression, treatment for the average American making minimum wage is still a long way away.

www.huffpost.com

I didn't really like the vagueness of the suggestion that Congress should just pass a bill when Fetterman returns. We've already passed the ACA, many states have expanded Medicaid, and yet psychiatry has one of the lowest rates of accepting Medicaid. This wasn't suggested, but I assume the solution must involve Medicaid reimbursement rates—or the author just made the general hand-waving suggestion of passing a bill without thinking about it. My instinct, from my station in life, is to balk at the idea that the solution is to give the relatively wealthy more money in return for accepting Medicaid, especially when one of the reasons psychiatrists take Medicaid at lower rates is that the patients are by definition relatively poor and have the problems that go along with that. Adding money to the relatively wealthy side of the equation just seems just wrong: Pay people more to incentivize seeing people who are less desirable at least in good part because they are poor. The problem, in part, wouldn't exist without the poverty to begin with. Then again, I don't really know what the author intends with their vague suggestion that Congress pass a bill to give everyone the level of access Fetterman has. Any egalitarian and well implemented solution for healthcare would improve access for some and worsen it for others and improve it overall. The idea that everyone should have access like Fetterman doesn't seem well thought out; we can't by definition all be the exception.

Edit: This was the part I was responding to:

"So, while I do wish nothing but a full recovery for Fetterman, I hope that once he returns to the Senate, he does indeed sponsor a bill that makes the kind of treatment he is receiving more accessible to average Americans."

 

[clausewitz2]

This coverage and opinion piece on many Americans not having the level of access as Fetterman I thought was much better than the talk about battling stigma:

Opinion: What Does John Fetterman's Mental Health Say About America

While the Pennsylvania senator has been open about his recent depression, treatment for the average American making minimum wage is still a long way away.

www.huffpost.com

I didn't really like the vagueness of the suggestion that Congress should just pass a bill when Fetterman returns. We've already passed the ACA, many states have expanded Medicaid, and yet psychiatry has one of the lowest rates of accepting Medicaid. This wasn't suggested, but I assume the solution must involve Medicaid reimbursement rates—or the author just made the general hand-waving suggestion of passing a bill without thinking about it. My instinct, from my station in life, is to balk at the idea that the solution is to give the relatively wealthy more money in return for accepting Medicaid, especially when one of the reasons psychiatrists take Medicaid at lower rates is that the patients are by definition relatively poor and have the problems that go along with that. Adding money to the relatively wealthy side of the equation just seems just wrong: Pay people more to incentivize seeing people who are less desirable at least in good part because they are poor. The problem, in part, wouldn't exist without the poverty to begin with. Then again, I don't really know what the author intends with their vague suggestion that Congress pass a bill to give everyone the level of access Fetterman has. Any egalitarian and well implemented solution for healthcare would improve access for some and worsen it for others and improve it overall. The idea that everyone should have access like Fetterman doesn't seem well thought out; we can't by definition all be the exception.

Edit: This was the part I was responding to:

"So, while I do wish nothing but a full recovery for Fetterman, I hope that once he returns to the Senate, he does indeed sponsor a bill that makes the kind of treatment he is receiving more accessible to average Americans."

People respond to incentives. If you want people to do more of something, you either need to incentivize them or punish them for not doing it. The former more reliably produces the behavior you want. If you want more mental health providers seeing people with Medicaid, make Medicaid either pay better, be easier to work with, or some combination of both.

You can be a purist about whether mental health providers are deserving of being paid more or you can do something likely to get more people on Medicaid seen. Not sure you can do both.

 

[birchswing]

People respond to incentives. If you want people to do more of something, you either need to incentivize them or punish them for not doing it. The former more reliably produces the behavior you want. If you want more mental health providers seeing people with Medicaid, make Medicaid either pay better, be easier to work with, or some combination of both.

You can be a purist about whether mental health providers are deserving of being paid more or you can do something likely to get more people on Medicaid seen. Not sure you can do both.

You can also create a moral calling. There are some things people aspire to regardless of pay and that society implants in people as aspirational. We have doctors without borders; we can have doctors without borders within our borders—it would obviously need a better name.

You can—and people have—made a case that Medicaid is a social contract and that doctors who don't accept it are abrogating that contract. That's not the most persuasive argument, as it involves shaming a group of people who can chose to ignore it and live great lives.

Obama made a call for men to step up to be fathers. Not sure how well it worked. But worth a try to make a shout-out in a state of the union for doctors to step up and take Medicaid?

I agree though that money is an incentive and water flows downhill as they say. I've long felt that one of the problems in the US is how large the personal investment in medical education is which seem to create a mindset early on of getting a return on investment. It's obviously not the only way in which money is problematic in medicine, but medicine for doctors does seem to be a high-stakes investment game in which making a decision in choosing a specialty and whom to panel with has a lot to do with the debt you've taken on and how high the ceiling is with regard to income. You can pour more out for doctors who take Medicaid, but it's just a bit depressing with how much excess is already spent with our cobbled together, balkanized sets of systems that define inefficiency, moreso when if you redistributed that wealth to the very people receiving Medicaid as something like UBI rather than increasing reimbursement rates you'd see less of the factors that play into mental health problems. Even more depressing when you consider that Medicaid has limits on assets (in my state) of $2,000. That's an immiseration program. That means people cannot plan or save to have a better life. So when you talk about paying people who are relatively wealthy even more to see those who aren't even able to save the money they earn from low-paying service jobs without losing the little insurance they have, my instinct is to say: Step up and take Medicaid as part of the social contract.

But again I understand it's maybe not the most persuasive argument, and I understand psychiatry is already a somewhat lower paying specialty and people willing to take Medicaid are reimbursed evenless, and we already have settled on being extremely inefficient—the system is settled in place—so yeah, it's not by far the worst crime in healthcare to add a little more to the reimbursements. It's just one small part of why healthcare in the US is so expensive with worse results.

 

[hamstergang]

If you want more mental health providers seeing people with Medicaid, make Medicaid either pay better, be easier to work with, or some combination of both.

Much yes to the bolded. Being easier to work with would incentivize me much more than increased pay.

 

[splik]

My instinct, from my station in life, is to balk at the idea that the solution is to give the relatively wealthy more money in return for accepting Medicaid, especially when one of the reasons psychiatrists take Medicaid at lower rates is that the patients are by definition relatively poor and have the problems that go along with that. Adding money to the relatively wealthy side of the equation just seems just wrong: Pay people more to incentivize seeing people who are less desirable at least in good part because they are poor. The problem, in part, wouldn't exist without the poverty to begin with.

This is nonsense. Psychiatry is a bit different from other specialties in that there is a whole subfield and setting dedicated to caring for patients who are on medicaid. It's called public psychiatry (also called community psychiatry). It varies from state to state, but in general, medicaid does not reimburse psychiatry services sufficiently for it to be a valid method of payment. Thus psychiatric patients on medicaid are largely treated in publicly funded settings. These clinics are funded by state and federal grants as medicaid does not usually pay sufficiently to cover the cost of a psychiatrist (i.e. unlike medicare or commercial insurance, billing the programs aren't sufficient to cover services). In california, none of the University of California hospitals (technically all public institutions) routinely accept medi-cal patients in their psychiatry clinics.

That is not to mention that medicaid patients are more likely to have significant psychosocial complexity, less likely to show up, less likely to adhere to treatment, more likely to have experienced trauma, more likely to have serious mental illness, more likely to have substance use disorders, and more likely to need case management and additional services. These services do not pay for themselves and are no paid for by medicaid. They rely on block grants or charity.

You can also create a moral calling. There are some things people aspire to regardless of pay and that society implants in people as aspirational. We have doctors without borders; we can have doctors without borders within our borders—it would obviously need a better name.

You can—and people have—made a case that Medicaid is a social contract and that doctors who don't accept it are abrogating that contract. That's not the most persuasive argument, as it involves shaming a group of people who can chose to ignore it and live great lives.

MSF is a highly prestigious and selective program; global health is seen as sexy and attracts all the narcissists. Public psychiatry not so sexy (though still manages to attract its fair share of narcissists). I've treated patients throughout my career regardless of ability to pay. But I have not found that to work in private practice.

Medicaid is not a social contract and I've never heard of this case being made. historically there is an argument that physicians have a social contract which includes providing care to patients regardless of ability to pay. However, this contract has been nullified over time for 5 reasons: 1) physicians no longer run healthcare; 2) the rise of insurance; 3) the rise of medicare and medicaid; 4) the cost of medical education and 5) liability of medical practice.

In the past physicians were the ones that controlled their fates; hospitals were places that they came to work at, not where they were employed. Today most physicians are employed and administrators decide what patients they seen. Often these organizations including public institutions incentivize physicians to see patients with private insurance and not to see patients with medicaid and medicare. Many physicians experience moral distress or moral injury because even though they work at public institutions or non profits, they are forced to consider the bottom line of the organization they work for. They may even be disciplined for trying to care for patients on medicaid and medicare.

Second, once upon a time physicians took whatever payment their patients would offer, which could include non-pecuniary payment (e.g. chickens). However, health insurance became a popular benefit that unions negotiated for their members which fundamentally altered the doctor-patient relationship by the incursion of a 3rd party.

This was followed by the social security amendments of 1965 that gave us medicaid and medicare which brought the federal government into the doctor-patient relationship. For psychiatry, the government decided the states should bear the brunt of the cost of psychiatric care (which was more heavily hospital based) capping medicare at a lifetime of 190 days for psychiatric inpatient care. Once government got its hooks in healthcare, the onus shifted from physicians to provide care for all to the government.

Fourth, the costs of medical education have skyrocketed in recent years. In 2019 (the last yr data is published), AAMC put the median cost of attendance at a private medical school at over 330k (once you factor in student loan interest, the figures are much worst). In other countries that expect physicians to serve the public, the cost of medical education is heavily subsidized or free.

Finally, the American legal system expects tort law to determine standards of medical practice. This bloats the overall cost of healthcare due to defensive medicine, and makes physicians less likely to provide pro bono or low fee care in their own clinics. If I treat a patient at an FQHC or the VA, I'm protected from liability by the FTCA, but if I see a patient for free in my own private practice I am not. No good deed goes unpunished.

 

[Sushirolls]

You can also create a moral calling. There are some things people aspire to regardless of pay and that society implants in people as aspirational. We have doctors without borders; we can have doctors without borders within our borders—it would obviously need a better name.

You can—and people have—made a case that Medicaid is a social contract and that doctors who don't accept it are abrogating that contract. That's not the most persuasive argument, as it involves shaming a group of people who can chose to ignore it and live great lives.

Obama made a call for men to step up to be fathers. Not sure how well it worked. But worth a try to make a shout-out in a state of the union for doctors to step up and take Medicaid?

... my instinct is to say: Step up and take Medicaid as part of the social contract. ....

So much to unpack here. Here we go!

America is not a socialist country. My services are not owed to any one... unless I choose to take a person on as my patient. I've paid more than "my fair share" to coin another socialist talking point to the Health Care System and society. My years of busting my buttocks in school, neglecting my personal health, missing family funerals, doing research in labs for advancing knowledge during educational breaks/vacations, being victimized by the socialist soap boxes of liberal professors year after year you have to endure and stay silent for, skipping a honeymoon, having a surgery on a Friday back to work on a Monday for my patients, embarking into the world of debt to fund my education, having already paid back - just in interest - more than the original principal balance, having a work ethic that exceeds most of every day America and working in parameters that most of America would file lawsuits over. Because I believed in the classic paradigm of professionalism, the tradition of Physician. Having patients threaten to kill me, filing restraining orders, getting yelled at, nasty Google reviews, being viewed as a mere means to an end [disability / STD / return to work paperwork, or ESA letters]. Getting sent nasty letters by insurance companies [see the Change Healthcare thread]. Neglecting my family to chart in the evening and weekends. Ever present threat of lawsuits, losing sleep over patient management and how that correlates back liability risk. Watching my practice overhead ever rise with standard business practices and inflation, but not being able to do the same tell the insurance companies your turn, now your rates 3% higher - so my income goes down.

Now Medicaid specifically has populations that require so much more time - that's one hit. AND you paid a fraction of what reasonable would be so that's a double hit. In essence you will get paid ~20-25% for the total time spent, compared to possible commercial insurance or cash pay. But now you also carry more liability for a population rife with other issues. If I take Medicaid. I can't keep my lights on and pay my overhead. I can't stay in business. I have to go back to working for a Big Box shop, which does things behind the scenes to limit their Medicaid population. Oh, I don't get tax deductions like Big Box shops do as non-profits. I don't get grants like large non-profits get for their new cool flavor of helping population X for the next 2 years or whatever. Medicaid is a massive, massive pain to submit to and collect from. The Sleep Doc who used to sublease from me felt this so called social contract, but only a fraction of the claims this doc submitted.... and resubmitted ... would get paid. This person was struggling and breaking down their convictions to help the population but was more than charity BECAUSE it eats up staff time to process these claims, rejections, to call, to wait and then get no answer or the wrong answer, and then repeat again several weeks later. Any time a doctor office has to call the insurance company it is a 30-45 minute ordeal. My assistant's least favorite things are claim issues that necessitate a call because it wastes your day. We haven't even gotten into the less talked about things... Medicaid patients may also smoke more... so they role into the wait room and all the rest of your patients are coughing and gagging form 2nd hand smoke [nicotine AND/OR cannabis]. Medicaid patients may also not practice typical hygiene standards, again your waiting room now smells. Your private insurances patients are like WTF? and they don't want to come back, so you take another hit for you business by losing a better paying patient. I don't have the social services to help the social dysfunctions in Medicaid populations. Then there is the Prior Authorizations that exist with medicaid for even the appointments - because medicaid is financially broke at each state and trying to cut costs - and the Prior Authorization for even medications; which is time and means staff and means more overhead. So, I'm supposed to be a virtue signaling saint for The State because they have tight purse strings in an underfunded program? That in some ways shouldn't exist? Government shouldn't be involved in healthcare. We have supplanted the religious faith based sectors, and their missions of humanity, and completely usurped them with a government take over. Government largely does a horrible job at running things which is why the tradition of America is not a socialist country and loathes the government and doesn't trust it.

I worked at a catholic hospital/system in the past and one of the common stories at that place was "things were better when the nuns ran this place." The nuns got old, relinquished their control to admin and Big Box shop management, things went down hill. The loss of folks going into the cloth, means nuns/priests aren't around to truly run catholic hospitals. People might want to criticize for abortion/birth control topics as a defining lightening rod to care in such facilities, but people gloss over the greater good they did for charity and other services, and how they ran their HR departments for their employees. I'm sure the same could be extrapolated to the other religious base hospital / health systems too. What we got now? More government...

If you look at the break down of medicaid in perhaps your state, you'll see Psych chews up a large very large amount. Dialysis another.

I, nay we, owe nothing to society. They owe nothing to us. And this has clearly been shown. Lawsuits. Hospital Admin. ARNPs. Scope of practice creep. Nursing that doesn't follow orders any more but bends the will of hierarchy to their whims under "Doctor, I don't feel comfortable with that."

Should the nightmare of a day ever come to fruition where my services are mandated by legislation for population XYZ. I quit. As the legal system stands, it can't, and won't happen.

But let's say it does... if this were to ever pass, and incomes likely would fall for physicians AND all other healthcare people/admin, because quickly, the insurance race to the bottom would no longer be to medicare but now Medicaid rates. I and many others would quit. New younger generations wouldn't want to become physicians. ARNPs would inherit the medical sphere. All the physician Economic immigrants wouldn't bother. Why would an Indian come to practice medicine in America if they can't make notable income? At least in Indian the patients will respect them, they won't get sued, they can be surrounded by the culture/population they know, the food they know, and cheaper labor [drivers/cooks/maids] that they don't have access here in America. *Substitute India with most any other country/ethnic group. So now, we just accelerated the death of the American healthcare system, and as much as people want to say 'we have the umpteenth worse healthcare system in the world despite spending buckets' we'll now truly have a crappy health care system that no one bother to accuse as good.

 

[Sushirolls]

....No good deed goes unpunished.

So much truth to that statement. And even the adjacent concept, no good intentioned exception goes unpunished, too.

 

[TexasPhysician]

You can also create a moral calling. There are some things people aspire to regardless of pay and that society implants in people as aspirational. We have doctors without borders; we can have doctors without borders within our borders—it would obviously need a better name.

You can—and people have—made a case that Medicaid is a social contract and that doctors who don't accept it are abrogating that contract. That's not the most persuasive argument, as it involves shaming a group of people who can chose to ignore it and live great lives.

Obama made a call for men to step up to be fathers. Not sure how well it worked. But worth a try to make a shout-out in a state of the union for doctors to step up and take Medicaid?

I agree though that money is an incentive and water flows downhill as they say. I've long felt that one of the problems in the US is how large the personal investment in medical education is which seem to create a mindset early on of getting a return on investment. It's obviously not the only way in which money is problematic in medicine, but medicine for doctors does seem to be a high-stakes investment game in which making a decision in choosing a specialty and whom to panel with has a lot to do with the debt you've taken on and how high the ceiling is with regard to income. You can pour more out for doctors who take Medicaid, but it's just a bit depressing with how much excess is already spent with our cobbled together, balkanized sets of systems that define inefficiency, moreso when if you redistributed that wealth to the very people receiving Medicaid as something like UBI rather than increasing reimbursement rates you'd see less of the factors that play into mental health problems. Even more depressing when you consider that Medicaid has limits on assets (in my state) of $2,000. That's an immiseration program. That means people cannot plan or save to have a better life. So when you talk about paying people who are relatively wealthy even more to see those who aren't even able to save the money they earn from low-paying service jobs without losing the little insurance they have, my instinct is to say: Step up and take Medicaid as part of the social contract.

But again I understand it's maybe not the most persuasive argument, and I understand psychiatry is already a somewhat lower paying specialty and people willing to take Medicaid are reimbursed evenless, and we already have settled on being extremely inefficient—the system is settled in place—so yeah, it's not by far the worst crime in healthcare to add a little more to the reimbursements. It's just one small part of why healthcare in the US is so expensive with worse results.

As Medicaid is currently structured, I’ll go as far as argue that no private practice psychiatrist should accept Medicaid AT ALL.

Here is a brief story of a peer - we will call him X. Child psych is in relatively short supply. Being relatively young, X decided to open a private practice accepting many plans including Medicaid. X had a sense of purpose that believed everyone deserved his great care. News spread quickly that X took Medicaid and being child psych, a rare thing. New Medicaid evals flooded the clinic.

At first, X thought his clinic would be very successful as there was no problem filling his schedule on paper. Unfortunately his no-show rate was super high, as is common with Medicaid. Medicaid also reimburses much less than any other plans in the area by far. You can’t charge no-shows by Medicaid law either.

X had estimated gross revenue at the start, but with Medicaid holding him down, the numbers were over 60% lower than expected. He was barely paying his overhead many months in. X next thought to overbook the clinic to try and keep Medicaid. Doubling up on evals led to new problems. While sometimes no one showed still, other times everyone did at once. Patients complained and left at needing to wait so long. Others didn’t feel safe waiting around the adult Medicaid patients. Negative reviews mounted and better paying insurance patients stopped calling.

Still not wanting to drop Medicaid, X hired a NP on salary to try and help with a periodically overbooked clinic. This helped with complaints that were starting to burn him out, but the added revenue from the NP didn’t cover salary/benefits.

Combined with debt payments, X couldn’t sustain the clinic. X closed the clinic.

After so much effort and passion and time, X was largely demoralized. Instead of helping any part of the local population, X removed himself from the child psych supply by taking some time away from medicine.

Later X returned to child psych taking a contract job that required minimal effort. He was to fulfill a government contract to have a child psych on staff. There wasn’t actually a need for a FT child psych, but governments aren’t efficient. He sees about 2 new evals in 10 hour shifts and most patients are treated for an adjustment disorder. Complete waste of resources of X’s training and our tax dollars. Maybe after more time, X will regain his passion.

X should have taken a job at a FQHC or other grant assisted clinic from the beginning. X probably would still be helping the Medicaid population if so.

Another knock on Medicaid:

In my private practice, I have a contract to see patients currently released from prison on probation/parole or awaiting sentencing. The government pays me over 5x the Medicaid rate to see released patients with these felony charges. Medicaid is so poorly run that they’d have much better care by picking up a felony charge.

It is not the job of psychiatrists to pick up the slack of a failed government program. Medicaid is a program designed to fail. It requires grants at community centers to survive at all. Anyone considering Medicaid in private practice should walk away for their own mental health.

 

[Merovinge]

As Medicaid is currently structured, I’ll go as far as argue that no private practice psychiatrist should accept Medicaid AT ALL.

Absolutely, if you want to take care of Medicaid in CAP, you work for an academic program period. You can see a very high % medicaid at very prestigious academic institutions and a huge number of them are looking for clinical CAP attendings to make the poor pay associated with this work.

 

[TheRightMedication]

I see a few medicaid patients for the cash price of 5 to 10 packs of cigarettes. No way would I ever engage with the Medicaide system.

 

[ObsequiousAplomb]

I see a few medicaid patients for the cash price of 5 to 10 packs of cigarettes. No way would I ever engage with the Medicaide system.

prison packs, gas station packs, or reservation packs?

(I know you're being facetious but I'm having fun so I'll continue anyway)

A pack of cigarettes is $11 in NY. $110 would be pretty good from a Medicaid patient. It's $5 in MO, and $50 is close to what Medicaid pays where I am. In prison, a pack could be $100 or more...

 

[TheRightMedication]

50 bucks, about.