Why Shared Decision Making Should Apply to Informed Consent

Erica Spatz Photo

Based on an interview with Erica S. Spatz, MD, MHS,
Assistant Professor of Medicine, Yale School of Medicine

Imagine that you’re about to be wheeled into surgery. You’ve fasted for 24 hours, you’re in a hospital gown, and you’re awaiting the doctor’s arrival. Then the nurse brings in some paperwork, and you’re asked to sign a form acknowledging the risks of the procedure. You see some potential side effects or consequences that concern you—but at that point, how likely are you to refuse the procedure?

For many patients, that last-minute signature is the only experience they have with informed consent. Legally, however, informed consent is defined as the process in which a patient learns about and understands the purpose, benefits, and potential risks of a medical or surgical intervention.

In my view, that discussion should begin long before surgery day, so a patient has time to balance the risks and benefits before moving forward with a decision.

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Telemedicine Can Help Solve Our Mental Health Care Crisis

Photo of Matt Mishkind

Care for Your Mind acknowledges and appreciates the collaboration of the National Network of Depression Centers in developing this post.

Matt Mishkind, PhD, Rachel Griffin, APN 

In the age of the smartphone, communication is easier than ever. We have face-to-face conversations with people thousands of miles away and access information with the swipe of a finger. And this amazing technology isn’t just for playing Pokemon Go or posting to Facebook—it has the potential to change the delivery of mental health care in this country.
With Skype and other teleconferencing software available on every smartphone, tablet, and computer, telemedicine has become an important industry. By using technology to connect a patient and a provider at a geographic distance, telemedicine can expand access to care for underserved communities, make treatment more convenient for patients, and improve efficiency across our healthcare system.

For thousands of patients in need of mental health care, from veterans to elderly patients to those with disabilities, tele-behavioral health can offer a life-changing solution.

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Insurance Coverage Doesn’t Guarantee Timely Access to Care

Picture of Simon F. Haeder

Simon F. Haeder, Ph.D.
Assistant Professor of Political Science, West Virginia University

With a national shortage of healthcare providers and insurance companies continually seeking to contain costs, it’s no secret that networks are shrinking. And as more patients opt into Affordable Care Act plans, there’s a lot of chatter about whether patients with marketplace plans (most of whom are lower income and rely on subsidies) face restricted access to care.

But when it comes to actually comparing these new marketplace plans to traditional commercial plans, there’s not much in the way of data. So, my colleagues and I decided to conduct a secret shopper-style survey of 743 primary care providers throughout California.

Our findings were revealing. While there was little difference between commercial and marketplace plans, both performed poorly. Less than 30% of patients—for both plans—were able to get appointments with the primary providers of their choice.

The research proved insurance coverage doesn’t necessarily guarantee timely access to care. In order for our healthcare system to improve, we must start giving patients accurate information and adequate networks so they can access the care they need and deserve.

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The Good News: You Now Have Health Insurance. But Will You Be Able to Access a Psychiatrist?

Depression and Bipolar Support Alliance

“Worsening of symptoms,” “inability to work,” “hope for the best,” “stretch my medication” are a few of the reported consequences people face when they are unable to obtain an appointment with a psychiatrist. These responses and others like it come from a survey conducted by the Depression and Bipolar Support Alliance (DBSA) that revealed the challenges people face when their health insurance plans lack an adequate number of in-network psychiatrists. The short survey revealed that 38% of respondents were not able to make an appointment with an in-network psychiatrist and 40% believed the wait time between seeking an appointment with a psychiatrist and being seen was too long.

A mental health parity issue
DBSA and other mental health organizations have taken on this concern as a mental health parity issue. One of their goals is to advocate for solutions by identifying and defining the problem. Building on what was learned from the previous survey, DBSA is seeking more insight into the lengths individuals and families go to obtain care. To that end, we invite everyone to take our Access to Psychiatrist survey.

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New Jersey Parity Coalition Uses Multi-Pronged Strategy to Fight Insurance Plan Inequities

Picture of Aaron Kucharski

Aaron Kucharski, New Jersey Parity Coalition

 What happens when there are laws on the books granting you equity, but when you try to use them as intended, you meet nothing but obstacles? That’s what many family members in New Jersey were asking when they tried to take advantage of the new mental health parity laws that increase access to care. Among those individuals was Valerie Furlong, who was seeking care for her two teenage sons. When she connected with other family members facing similar challenges, Valerie quickly learned that she was not alone in her frustration. She and others like her decided to take action against these obstructions and join forces with the New Jersey Parity Coalition.

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We Have Mental Health Parity Laws! Is Our Work Done? Implementing and Enforcing Mental Health Parity at the State Level

Picture of Kelly O’Brien

Kelly O’Brien, The Kennedy Forum Illinois

When the historic Mental Health Parity and Addiction Equity Act of 2008 (“Federal Parity Law”) was enacted, Americans expected to have fewer barriers to access mental health and addiction services, and expected that behavioral health benefits would be provided on par with other medical/surgical health plan benefits. As Tim Clements of ParityTrack shared in a previous CFYM post, it is largely the state regulatory agencies that are responsible for implementing and enforcing the Federal Parity Law. Unfortunately, it’s now eight years since MHPAEA became law, and most states have not fulfilled that obligation, including Illinois. The result is that health plan beneficiaries continue to be denied access to behavioral health services and remain unaware of their right to access care as a part of their health plan’s covered benefits.

Authored by former Congressman Patrick J. Kennedy, founder of The Kennedy Forum, the law requires health insurance plans to guarantee that financial requirements and limitations on treatment benefits for mental health or substance use disorders are no more restrictive than the insurer’s requirements and restrictions for medical and surgical needs. The Affordable Care Act (sometimes known as Obamacare) expanded the Federal Parity Law to apply to even more health insurance plans.

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Equal Health Insurance Benefits Is the Law, But Are the States Enforcing It?

Tim Clement Photo

Tim Clement, Policy Director, ParityTrack

For most of the history of modern American health care, mental health treatment was not covered by insurance the same way other medical treatment was covered. Insurance plans often implemented arbitrary and restrictive annual and lifetime limits on inpatient days and outpatient visits. Copayments and coinsurance rates were often far higher than they were for other medical care. Separate and more expensive deductibles for mental health care were the norm.

Thankfully, the Mental Health Parity and Addiction Equity Act of 2008 (the Federal Parity Law) made this form of separate and unequal insurance coverage illegal. The Federal Parity Law prohibits insurance plans from imposing treatment limitations and financial requirements that are more restrictive for mental health and substance use disorder treatment than those used for the treatment of other medical conditions.

The good news is that health insurance coverage that discriminates against people with behavioral health conditions is now against the law. The bad news is that nearly a decade after President George W. Bush signed this landmark piece of legislation into law, insurance coverage for treatment of mental illness and addiction still is not on par with insurance coverage of other medical conditions.

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Shared Decision Making – with Families – Yields Better Treatment Outcomes

Alison M. Heru, M.D.
Professor of Psychiatry, University of Colorado Denver

In the NES Program at University of Colorado Health, a six-month program combining neurology and psychiatry treatment for non-epileptic or non-electrical seizures, psychiatrist Dr. Alison Heru makes shared decision making an integral part of practice.

In my experience, shared decision making yields the best results in treatment. When patients feel like they have participated in choosing the treatment and are able to ask questions and weigh alternatives, they are more likely to feel they have selected the treatment that is the best for them and have a stronger stake in the outcome.

At the NES program (addressing non-electrical seizures), there’s not clear evidence for which treatment approach will be best for each patient. It’s my role, then, to make sure we make the correct diagnosis, provide information about the treatment modalities available, and decide together with the patient (and the patient’s family, unless not available) on the treatment plan. I won’t tell the patient what to do or to force a choice on them, but I will offer my opinion.

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