Dear Atul Gawande: As you go on your listening tour, don’t forget about mental health

It’s too early to know Dr. Atul Gawande’s priorities in his new role as CEO of the yet-to-be-named health care venture of Amazon, Berkshire Hathaway, and JPMorgan. My colleagues at STAT report that before anything else, he’ll embark on a listening tour.

So, Dr. Gawande, I’d like you to listen to me for a moment: Whatever you create, however you disrupt, you need to treat the mental health needs of the people you serve with the same consideration and care as their physical health needs.

On a recent Sunday, I evaluated a woman in the emergency room who was so depressed she had stopped eating, stopped sleeping, and had become increasingly paranoid. She was in crisis, and I needed to admit her to an inpatient psychiatric unit for treatment.

So began a bureaucratic nightmare that has come to define one of my most frustrating challenges in providing good, meaningful mental health care. It’s a nightmare that is not only discriminatory, but also dangerous, and exacerbates health disparities. And it’s an antiquated throwback that wastes doctors’ time and hospital resources, and reduces efficiency.

She needed prior authorization from her insurance company to be admitted, and the office that could do it wasn’t open overnight or on the weekends.

My fear is that if Dr. Gawande and other health care innovators don’t put mental health front and center, they will fail to put our patients first because there is no health without mental health. Furthermore, it will be a missed opportunity to address the tremendous waste in the system.

I called my patient’s insurance company, and navigated a labyrinth of “press 1” for this and “press 2” for that, trying to find a human being to authorize her admission. This was precious time I could have been spending with her, or another patient who needed me that Sunday afternoon.

Once I finally reached someone, and was told that no one could provide this authorization on the weekend, I asked flat-out why any company would have such a discriminatory practice — had my patient been having a physical crisis, like a heart attack, she would have been admitted in an instant.

Then there was more time on the phone, waiting for a supervisor to weigh in on the situation, and to decide whether he or she could help.

But my effort was futile. She could not be admitted, and would have to spend the night in the emergency department. I handed her a warm blanket and could only apologize over and over while fearing this experience would keep her from seeking help the next time she needed urgent psychiatric care.

My time on the phone was bad for medicine and her experience with her insurer was bad for her health.

In general, patients requiring psychiatric hospitalization wait up to 5.5 times longer in the ED to be admitted than patients entering with non-mental-health concerns. People who are uninsured or have public insurance wait the longest, and this means a higher chance of medication errors and poorer outcomes. In the case of my patient, by delaying her care, her insurance became a liability, and not the lifeline it should have been.

As for me, a psychiatry resident, a small study found that we spend about 38 minutes on average per patient dealing with prior authorizations for inpatient admissions. This time on the phone is time I am not practicing medicine, and not working at the top of my license. One of my attendings, who was part of that small study, estimated that 1 million hours are wasted each year in the United States this way. And few other physicians have to do this kind of clerical work for emergency care.

Dr. Gawande, as I was on the phone with my patient’s insurance company, I was reminded of your writing about efficiency, avoiding mistakes, and providing the best patient care. I also thought about how this prior authorization issue wasn’t going to change with a supervisor, or even that person’s supervisor. It has to come from the CEO, the person who signs off on the company’s practices.

This is why I’m writing to you. You’re now a CEO, and as you go forward in this venture, here is my checklist for you on ways you can innovate to improve mental health insurance practices in the U.S.

• End prior authorizations for inpatient and outpatient treatment, which often involves getting permission to give patients medications or get admitted to day programs that are essential to their care.
• Reimbursing mental health practitioners appropriately for their time and expertise so that more of us are excited to join insurance panels. This will allow you to prioritize prevention by improving access to ongoing outpatient psychiatric care and therapy.
• End the insurance practice of denying inpatient admissions for people with mental illness who present with substance abuse problems. The two often go hand-in-hand, and refusing to authorize admissions driven by substance abuse contributes to the stigma associated it.

Efforts to codify parity through the Affordable Care Act have been important first steps. But, you have an extraordinary opportunity to put into practice so much of what you preach, so much of what you teach, when it comes to efficiency, preventing medical mistakes, and ensuring that everyone has access to the best possible health care our nation can provide.

Thank you for listening.