We talk with Nick Rosenlicht, MD about what’s gone wrong in the mental health care system.

Publication Date: 12/09/2024 

Duration: 23 minutes, 57 seconds 

KELLIE NEWSOME: Welcome to the Carlat Psychiatry Podcast, keeping psychiatry honest since 2003. 

CHRIS AIKEN: I'm Chris Aiken, MD the editor-in-chief of the Carlat Psychiatry Report. 

KELLIE NEWSOME: And I'm Kellie Newsome, a psychiatric NP and a dedicated reader of every issue.

CHRIS AIKEN: As we were finishing off the final edits of this podcast, we received the news that the CEO of UnitedHealthcare, Brian Thompson, was fatally shot not far from where we were recording in Midtown Manhattan. The words encased on the bullets made clear the shooter's intent. Deny, defend, depose, a reference to a book from 2020 called Delay Deny Defend, Why Insurance Companies Don't Pay Claims, and What You Can Do About It. Well, there's a lot you can do about it, and we're going to get into that in this podcast. And murder is not counted among them. But this podcast is not a reaction or a response to the events of the shooting. It's a reaction to a crisis that has been long-standing.

KELLIE NEWSOME: Nicholas Rosenlicht, MD has worked as a psychiatrist, teacher, and researcher for over four decades. It’s a career that has seen major advances: Clozapine, Prozac, TMS, and Dialectical Behavioral Therapy. But he’s also witnessed a degradation in how we care for people with mental illness, and that is the subject of his latest book, My Brother’s Keeper. Today, he talks with us about insurance denials, private equity takeovers, and how to reduce burnout in the age of healthcare productivity. Stay tuned to the end for an important clozapine update.

CHRIS AIKEN: You argue that healthcare has become a business where patients are called clients and doctors are providers. So what's wrong with all that? 

NICK ROSENLICHT: Mental health has been sort of extruded from his health care. It's not viewed as an illness, and I think public sentiment is changing. But in the past, the majority of Americans have not believed mental illness is real, and part of the mental health field has played into that. For example, calling people clients. Client implies it's a business, it's a decision that somebody else is going to fix the problem for you, not that it's an internal illness that you need to have assistance, but the burden of the healing happens within, and it turns into a business deal, which allows it to be extruded. Like why would health insurance pay for a client relationship? 

CHRIS AIKEN: I can see the argument, though, that it's more respectful or humanizing to call people clients instead of patients.

NICK ROSENLICHT: I think we do that because we all are steeped in the whole stigma of mental illness that calling somebody a psychiatric patient is damning. Brings up/evokes visions of insane asylums and people being insane, and who wants to be called a psychiatric patient, but in using a euphemism, it may make it more palatable for us to talk to somebody when they enter care, but in doing so, we're perpetuating and strengthening the stigma, but oh yeah, we won't talk about it either too, because it's really kind of disturbing. So we perpetuate it by trying to sanitize mental illness and think we can handle it with wellness or groups or the right diet. I mean, everything is important, but to not really view these as illnesses and people as patients, I think is a mistake, and that's what our model has been is viewing it as a business model, and making it a business model makes it more ethically palatable to exclude people from care or give them bad care, because after all, it's a business decision to not treat somebody because they can't meet the terms of the contract or deal, they don't have insurance, they don't have funds, or they're not choosing to, or they don't have the insight to realize they need care, and they won't pay is a lot easier than saying, I'm not going to treat you, and I don't care if you end up on the streets or in prison or dead. It makes it a lot easier for us to deny care the way our society does. 

CHRIS AIKEN: How does our society carve out the sickest among us from care?

NICK ROSENLICHT: One, you generally have to be employed to get insurance; for the seriously mentally ill, employment is hard. We used to provide sheltered workshops and jobs, and in asylums, people had jobs, and that's an important part of self-esteem and being part of society is to work. So it's based on employment, or if you're not over 65, Medicaid, which is incredibly cumbersome and administrative, and who's going to be able to handle the administrative task of receiving and managing yourself on Medicaid when you're homeless, or you don't have a cell phone, and people are often estranged from their family. We don't provide the resources necessary to keep people in care. It's very hard to negotiate our system. Businesses and psychiatrists are self-pay out of pocket 15 times more often than those to primary care. Again, we're pitting companies who are intending to make money against people who need care, and they are in opposition. You provide care. It costs money. Think about it. Health insurance is really not a kind of insurance; insurance. It's a pooling of resources people pay in to avoid a catastrophe like your spouse dies or your house burns down, and the community all shares in a small cost, so you will be okay; but health needs are not rare they're needed, especially preventive care. We all have to get care, so it's not really insurance. So we have this industry, which is supposed to take care of us, but their goal is to make money, and that's why there've been so many scams to get around parody, insurance coverage for mental health. I think there's also something around the privacy of mental health care because of the shame and embarrassment and all that people, their families, and we don't advocate enough. I think we could get together as groups to blacklist or shame even some companies that are unfairly discriminating against the mentally ill. I know in California, for example, Kaiser has been fined for their lack of providing mental health care, and I think others, but often these companies are fined. Paying the fines is cheaper than actually providing the care. 

CHRIS AIKEN: Some recent laws have tried to address those problems, like parity law and laws against excluding pre-existing conditions. How have those moves failed? 

NICK ROSENLICHT: The Affordable Care Act did have the number of uninsured, but it also entrenched the current players whose interest is to exclude mental illness. I mean, it's like whack-a-mole. I just read about this company, EviCore, sort of like the pharmacy benefit managers. It's a company that tells insurers, you pay me ten, and I will save you twenty by denying claims, and we don't get reimbursed for fighting claims or filling out PARs. With each roadblock that's put up, enough people just give up and won't do it, so it's a game of whack-a-mole, and I think that's why 50% of psychiatrists don't take insurance. 

CHRIS AIKEN: And all of those whack-a-moles create a bureaucratic wall that prevents parity?

NICK ROSENLICHT: I think just in denials, psychiatrists tend to have less of a system around them, and we tend to be more solo practitioners than internal medicine or surgery clinics who will have dedicated people who fight claims, denials, and as psychiatrists are now working more and more for these groups who often are owned by venture capital companies. They are not interested in spending time, fighting these things. They will just go after resource-rich people who can pay out of pocket, and I think with all these roadblocks, more and more, we go for the high payer and people who can't pay or are difficult, the work to get them care is just not profitable or practical over time; and the time it takes to fill out people's individual forms, and then you have to hire a biller; I think psychiatrists find it's just easier to take less payment and just not have to hire other people. It's so costly to have an office where you might have an office manager, or a biller, or people to manage this stuff.

CHRIS AIKEN: This sounds like an ethical dilemma. On the one hand, we can take insurance even though they may compromise our ability to deliver good care, or we can go private pay only and be free of those restrictions, but when we do that, we're also carving out a lot of people and moving toward treating just the worried well who can afford those kind of rates.

NICK ROSENLICHT: Well, it is a very real dilemma. I think some of us, what we do is I do that. I see wealthy people, but I also do some pro bono or low bono work. And I have things like, maybe I will charge people twice what they make as an hourly wage, or do some pro bono work just to feel like I'm doing the right part for society, and some people are paying more, but if you're not paying an office manager and all this stuff, you can do that and make a decent living. I think as cost of living has gone up and wages have gone up, we've gotten on the escalator expecting a lot of money, you see psychiatrists didn't used to make a lot of money that way unless you were treating diseases of the rich only.

CHRIS AIKEN: What are some of the models of private pay that psychiatrists are using when they don't take insurance? 

NICK ROSENLICHT: There's concierge, people buy in for an annual fee, get care, that's still, there's a problem in that a concierge fee might be prohibitive to one person, not for the other; and then the incentive is also to minimize care, because once they've paid their fee, why would you want to spend a whole bunch of time on them?

CHRIS AIKEN: Is there any hope of changing all this or at least negotiating with insurers? 

NICK ROSENLICHT: I think we have a whole lot more power than we think when we stand up to insurance companies. They are not negotiating. It's not a business deal they're giving us. They're giving us a nonnegotiable contract if you sign as a provider. How is that fair? And why should we do that? That we are just taking what they say. It means essentially, you are a gig employee of that company, where you have no rights, you have no say, and you take what they say you can have. How is that a fair deal? There's a paradox in that we are in demand. People need us. Why is it we have no power? We are the ones the insurers need. I mean, it's sad. I get calls every day from people wanting care, and I'm as full as I can be, and I want to be. I think it does mean banding together a bit more. Your physicians aren't supposed to strike. Our work is so private that getting together and talking with colleagues about, well, no, this insurer is doing better. We'll take that one, and they're forcing insurers to compete with each other to do a better job. Give us more power. There's that courtesy stigma about being a psychiatrist and that we're a Hannibal Lecter, or we're a what about Bob, or inept, or we're corrupt. I think having a better public face and talking about what we do, and how people can access us, and what are the way we do our work is important. I think our organizations have been too allied with pharmaceutical companies and big money rather than serving the needs of what psychiatrists and their patients need.

CHRIS AIKEN: What should we look for in an insurer to make sure that we contract with the ones that support good care? 

NICK ROSENLICHT: One thing is, I think, be careful about the groups you join. Make sure it's one run by psychiatrists. Why do you want a company that is making money off of you, hiring you, and these places with non-compete clauses and all that? But again, it would be talking to your peers, like, who do you contract with, and who not? Who has worked out well? I mean, that puts the pressure on the companies to do a good job; otherwise, people won't work with them. 

S AIKEN: OK, you just brought up non-compete clauses, which are very ethically problematic - not because they keep doctors from earning a living - I mean, we can find jobs - but because they break up continuity of care by preventing patients from seeing doctors who’ve switched jobs, but, isn’t the government trying to outlaw non-competes?

NICK ROSENLICHT: Well, yeah, but apparently nonprofits won't be bound to them, and there's ways around it, and there's so many nonprofits in health now who that just means they don't have stockholders. They're still making profit. So, it's what's going to be tied up for a while

KELLIE NEWSOME: Let's pause for a preview of the CME quiz for this episode. Earn CME for each episode through the link in the show notes. 

True or False: According to Dr. Rosenlicht, the majority of outpatient psychiatrists accept insurance.

CHRIS AIKEN: Private equity started buying up mental health practices a few years ago. What is happening with mental health centers that are not physician-owned? 

NICK ROSENLICHT: Venture capital and private equity are on the seven-year models to sort of pump up and dump, make some money, and then dump it, and that doesn't work in healthcare. I think private equity and venture capital are the largest investors in mental health over the last few years because the profits can be so great because of the model of just squeezing people because they're so desperate, and it's really unfortunate they're doing that. 

CHRIS AIKEN: Well, we've talked about a lot of problems today. What are your solutions?

NICK ROSENLICHT: I think we need to move towards a single-payer. I know people are scared by that, but every other developed country does that, and we do that, and we also view the ... brain is not different than other organs, it should be covered equally, there shouldn't be different restrictions on care. We shouldn't even talk about parity, the idea of there being a different care for diseases of the mind than of the liver, it just shouldn't occur. 

CHRIS AIKEN: Some clinicians are being pushed to see more and more patients per hour. 

NICK ROSENLICHT: I can see four people in two hours and make a lot of money charging them if they're just meds. But I don't feel I know them as well. I didn't cover all the bases. Maybe it's old school, I used to work in training, and you work like 88 hours, but you didn't burn out. You were tired because it felt fulfilling. After all, you felt like you were doing the right thing. You made a connection to people. You felt like you were being complete, and you weren't spending time on things like paperwork. When I sit with somebody, and I don't feel like I'm hurting them, I'm being fed too, because it's the relationship, It's the reciprocal care, that most of us went into medicine for, and burnout is not just workload, it's about lack of control and the lack of feeling that you're doing good care. What really feeds us is the feeling that we're doing a good job. Half an hour already feels rushed for me, and that's my training, I guess, in being old school and getting older, but I just would feel like a vending machine. And yes, I'm making a living, but I worked hard to get into medical school and go to medical school and then residency training and all this stuff, and I'm making an okay living, and at this point in my life, I'm not starving. It's more important to feel like I'm doing something that I enjoy and I'm helping people. Generally, happiness is more about not what we're doing for ourselves but what we're doing for other people, and I think that's why most of us went into medicine. That's what feeds us, and to get back to that rather than the dollar. 

CHRIS AIKEN: You said that you were inspired to write this book by negative changes in health care that you saw throughout your career. On the other hand, did you see any positive changes in your career?

NICK ROSENLICHT: Well, I think the public's view has changed. There was a time when a vice presidential candidate was kicked off the ticket (Eagleton) because it turns out he'd had successful ECT and was all better, but now, you've got people like Federman coming out with describing his depression. I mean, the number, I forget what it is, it's like, like 30% of Americans know somebody who's died of a drug overdose. So, I think that has shifted. Treating mental health is cost-effective. People use less other health care, and it saves money if we do this and I think there is a public awareness now that mental health does need to be addressed. So we have an opportunity now, and it's going to happen through legislators. The healthcare industry is the largest lobbyist in this country, but I think through people saying, No, no, no. This is part of a good world. It is us taking care of everybody, including their mental health. It just makes everybody happier. So I think there is an opportunity now, and that's why I was reaching for it. It's in the public eye now. 

CHRIS AIKEN: Thank you, Dr. Rosenlicht.

KELLIE NEWSOME: Last month, an FDA advisory committee voted 14-1 to end the clozapine REMS program. We expect a final decision from the FDA in the coming months, but it’s likely they will end or significantly loosen these restrictions, which require labs every 1-4 weeks before pharmacists can dispense the antipsychotic. 

CHRIS AIKEN: Clozapine was developed in the 1960s and first released in Europe in the early 1970s, but it was quickly taken off the market because of alarming cases of agranulocytosis, a fatal drop in white blood cells that occurs in about one in a hundred patients who take the drug. At the time, clozapine's main advantage when it was released was that it did not cause tardive dyskinesia, something that was getting to be a bit of an epidemic in the 1970s as doctors were turning to higher and higher doses of antipsychotics, to try to help people who weren't responding to them. It was only later that we learned of clozapine's benefits in treatment-resistant schizophrenia, a discovery that led to its rebirth and U. S. release in 1989. John Kane, who led that movement, as well as the landmark trial that showed clozapine could work for patients who failed multiple antipsychotics, spoke at the recent FDA meeting.

KELLIE NEWSOME: When clozapine was first released, the FDA required weekly blood draws indefinitely. In 2005, the regulations were relaxed to allow monitoring every 2 weeks after 6 months of treatment and every 4 weeks after a year. The change followed the evidence: Most serious cases of agranulocytosis occur within the first 4-5 months of starting treatment, and by two years, that risk is almost negligible.

CHRIS AIKEN: We've also learned a few things about clozapine that put its risk in perspective. First, patients live about ten years longer on clozapine than they do on other antipsychotics. Why? Well, I doubt that clozapine has anti-aging effects, but I do believe that a healthy brain is critical to a healthy body. Second, the regulations, the REMS appear to be causing more harm than good, with over 60% of psychiatrists saying that the REMS program prevents them from using clozapine. The US lags behind all other countries in clozapine use, with only 5% of US patients with schizophrenia taking it 5%, while the rate of treatment resistance in schizophrenia is 25%. In some countries, 25% of patients with schizophrenia do take clozapine. 

KELLIE NEWSOME: Agranulocytosis is serious, and we expect that regular monitoring will be part of the standard of care if not part of a REMS program. But it is not the only thing to worry about on clozapine. The rate of death from severe constipation – bowel obstruction and ileus – is greater than the risk from agranulocytosis, so ask your patients how often they are having a bowel movement on clozapine and treat aggressively, starting with Docusate-Sennoside combination first line. Seizures, metabolic syndrome, myocarditis, and arrhythmias are also important risks, and this year, a study identified higher rates of pneumonia as a possible risk from clozapine. 

CHRIS AIKEN: With so many risks, it's amazing that patients live longer on this drug, but that is a not uncommon paradox in psychiatry. Both lithium and clozapine have more medical warnings than other drugs in their class, but lithium and clozapine are also the only drugs in their class that robustly lower the risk of death in bipolar and schizophrenia. If you've been avoiding those options because they seem too risky, think again.

KELLIE NEWSOME: Nick Rosenlicht is a Clinical Professor of Psychiatry at the University of California, San Francisco, School of Medicine and operates a private practice in Berkley, California. His 2024 book, My Brother'sKeeper: The Untold Stories Behind the Business of Mental Health―and How to Stop the Abandonment of the Mentally Ill, is available from Pegasus and Simon and Schuster Books. Read the full articles and earn CME credits at thecarlatreport.com, where we have a special offer for our podcast listeners. You can get 30$ off your first-year subscription with the promo code PODCAST. That helps us stay free of influence from the pharmaceutical industry and bring you unbiased information you can trust.