October to December Disarray - Behavioral Health, Insurance, 2015 Redesign

Frontliners hang in there! It is indeed a tough time for 40% of Americans and those who attempt to care for them. Further deteriorations in access mean difficult times for primary care, emergency rooms, mental health facilities, and urgent cares. The end of this year brings new changes.

In the Arizona media there has been discussion about increasing behavioral health presentations to hospitals. I spared the link due to the usual excessive advertising. But after all, this is only the tip of the iceberg.

The Report from Arizona East Valley ERs and Urgent Cares

Mental health issues are being multiplied at the current time. Even though there is the potential for more care, the factors driving increases in mental health problems are up, access appears up (insurance) but is in decline (workforce changes), and there is even less ability to "fix" the problems. 
  • The country appears in an unsettling disarray with enemies foreign and domestic, 
  • The US has designed worsening economics where most people live - the cumulative impacts of state and federal cuts impacting much of the nation's population (economics, jobs, well being)
  • 90% of Americans are not benefiting from increases in wealth
  • Jobs have little change of advancement
  • Situations for children and their children are not improving
  • Family members are less able to support those with financial or mental health problems. They have depleted finances and increased exhaustion.
  • The usual political tear down has become even nastier close to voting time
  • Social media doom and gloom
  • New and expanded wars
  • A new TV season with major violence a theme
  • Declining public confidence in politicians, courts, police, sports - especially NFL issues, 
  • Those bringing their kids to the ERs and urgent cares for alleged abuses are up (wonder where they got the idea to bring kids in spanked with belts leaving bruises?), 
  • Doctors offices are shedding the more complex patients (not saying no but saying later, which means no), others are not signing up patients, cherry picking - a natural result of cuts in revenue and delays/denials plus increased costs of care
  • Breakdowns of primary care specific to small health care - 45% of primary care, increasing realization that some changes are required (concierge, direct primary care, employed work)
  • Changes of insurance with more restrictions on care
  • Disrupted continuity 
  • Family deterioration (Maricopa County adds to grandparents as parents category of families)
  • Overwhelmed mental health resources
  • Epidemics of STDs and not enough public health
  • People being refused care at various sites (just because you say you are primary care or urgent care doesn't mean you actually accept patients and take care)
  • Feelings of people controlling the political process with little say in the matter - more revelations about financial corruption, difficulty trusting public officials, and 
  • In the next week even more disorder due to hydrocodone going to schedule II with the least preparation of patients and providers for such changes.
It is hard to clear behavioral health as it just recycles and spreads without being addressed. This results in multiple visits to places who are unable to address behavioral health, and more side effects.
  • Plus high deductible insurance helps convince people to avoid the ER to go to urgent care (that can turn them down until they find someone who will care for them or has to care for them, worsening their situation). 
  • And continued strep, nasty viral sore throat, persistent fever virus, increasing drug dependency visits, continued epidemic norovirus, intriguing viral rashes, large area reactions from mosquito bites and/or cellulitis, and 
  • the beginning of the ebola scares… (The media will have a field day). Soon a number of patients with major fever will want ebola testing, especially after the ebola patient in Dallas was sent home for a few days.
  • Then a coming attraction is flu
Most of the above are specific to ER and urgent care. Primary care is dealing with insurance changes, cuts from insurance plans, changes in fees and coding, the usual delays, no increases in payment by federal design, threats of cuts, higher costs of delivery, increasing dissatisfaction from ever higher expectations, and patients ever more confused and forced into more changes.

For emphasis - There are three times as many urgent cares in the east valley in the past 2 years plus increases in retail care. Despite this, they all appear to have stable to increasing volume. More urgent cares and high tech designs are on the way.


Global Fails Local But Local Focus Succeeds Globally

Domino Decline By Design - as ERs Close, Those Nearby Face Challenges, as Small or Rural Hospitals Close or Practices Where Needed...

Declines in Health Care Delivery Despite Increases in Health Spending - If We Keep Accelerating Non-Delivery Costs, We Can Continue to Remain Behind Health Care Demand


Blogs indicate that primary care can be recovered and should be recovered.

Dr. Bowman is the North American Co-Editor of Rural and Remote Health. He was the founding chair of the Rural Medical Educators Group of the National Rural Health Association and the long term chair of the STFM Group on Rural Health.

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