28.1 Stop Abandoning the Severely Mentally Ill with Nick Rosenlicht, MD

[00:00:00] What would you recommend to patients who are dealing with just exorbitant medical bills? You know, those who have the time and ability doing what you do. But, you know, that's how it works. You get ground down. And that's how the system is working. And people who are depressed or anxious or maybe psychotic, these are not people who are going to pursue, you know, fight the system.

[00:00:26] The system is okay that you won and got your bill reduced because the fact is most people won't. Americans spend literally, I forget what the number is, it's like a billion hours on the phone with their health insurers. Far more than they spend with their doctors. Somebody get this guy some help.

[00:00:57] Disclaimer, this podcast is for informational purposes only. The information provided in this podcast and related materials are meant only to educate. This information is not intended as a substitute for professional medical advice. While I am a medical doctor and many of my guests have extensive medical training and experience, nothing stated in this podcast nor materials related to this podcast, including recommended websites, texts, graphics, images, or any other materials, should be treated as a substitute for professional medical or psychological advice, diagnosis, or treatment. All listeners should consult with a medical professional, licensed mental health provider, or other health care provider if seeking medical advice, diagnosis, or treatment. Or, put more simply... If you need help like this guy, call your own doctor.

[00:01:25] I'm thrilled and enthusiastic today to have on Dr. Nicholas Rosenlick, an MD and psychiatrist with over 40 years of experience in treatment and teaching. He currently works as a clinician and professor at UC San Francisco and is the founder of the UC San Francisco VA Mood Disorders Clinic.

[00:01:45] I became aware of your existence through your recent appearance on the Carlatte Psychiatry Report with Chris Akin in a follow-up phone conversation later that week. There were various aspects of your interview and our discussion that spoke directly to my passions from how insurance deprioritizes and defunds treatment of severe mental illness to how captured our field's research is by corporate interests and marketing

[00:02:14] to psychiatrists avoiding burnout by recognizing that adequate support, understanding, and treatment of our patients is not just some altruistic venture, but it's actually something that's beneficial to both the patient and the provider as we tend to value connection and healing as a couple of reasons why we went into medicine in the first place.

[00:02:38] In other words, spending a few extra minutes on patient care makes us feel more meaningful and fulfilled at the end of our day. That was such a powerful message, so I do appreciate you spreading it. And then you've also recently written a book titled My Brother's Keeper that we'll talk a little bit more about today. Did I miss anything there? No, I don't think so. I think you're touching on the whole idea of the physician, not just psychiatrist burnout.

[00:03:05] Because I think for me, you know, a couple hours working with a patient energizes me. 20 minutes on a phone call with a payer or a pharmacy beneficence manager or arguing about some administrative thing burns me out far more because we used to work incredible hours. I mean, as a resident, 80, 90, and we didn't burn out. We were younger.

[00:03:31] But what burns you out is a sense of helplessness and that what you're doing isn't really worth it or helping someone. We don't burn out when we're making somebody better or working towards improving somebody's life. We just don't. And our system is not geared towards that anymore. Yeah, absolutely. I wish I knew what it was like back in the day. But that's been the pretty much the entirety of my experience. It's become an adversarial world.

[00:04:01] I mean, the whole business model is an adversarial one. It's zero sum. More for me is less for you, whether that be, you know, a clinician and insurer or one patient or another. And it's made us have to watch what we say and how we behave. The way medicine should be that if you get better, I feel better. It's a better world when each of us gets better. That doesn't mean we can do everything for everyone, but it's a decision about what will make individuals and the community better.

[00:04:30] That's not how it is now when you've got health care, which is controlled because it's so expensive by someone in a different city who's not even a health care person who doesn't even know about the case. That has been just overwhelmingly frustrating for me is to try to explain myself to somebody who has no clinical experience, no training. And you quickly realize they're just there to deny, to take up your time.

[00:04:58] And if you spend enough time with them, usually you can get things covered. But it's the little blocks. I mean, it's the having to redo the prescription or write a quick letter. And sure, you can win. But your day end up, you spend an hour or two doing meaningless administrative tasks that burn you out. I think you already got the aspect of the interview being a little bit more laid back.

[00:05:26] The point of me doing this is coming from initially a journalism major and kind of have a writing background. Well, that explains how sophisticated it is. You have a journalism background. A little bit. I went journalism, sorry, history, journalism, and then went into psychology. And my dad said this to me. He's a urologist. He said, I know you pretty well, and you're not going to like being a psychologist and having a psychiatrist muddying around with your patients. It's funny.

[00:05:55] We did kind of come with some of the same ideas from opposite sides. My background was I ran a bike shop, a repair shop, an auto mechanic. I did most of an engineering degree. And then I was in environmental science. And psychiatry was sort of not on the radar. But you want to know how I got into it? Basically, I worked as an environmental biologist. And with a bachelor's in biology, you know, I was going to be a lab tech for the rest of my life. So what did I want?

[00:06:24] And I found that I really enjoyed people the most. And I loved, ever since I was a little kid, I took things apart and tried to fix them. And I thought about being a vet because I love animals. But I did work in a vet clinic for a while. But I remember these people coming in and go, why is my dog so crazy? Well, you know. But I didn't really expect to go into psychiatry, except I just enjoyed my psychiatry rotation the most. And felt I probably helped people the most.

[00:06:54] Also, as one of my co-residents said, you know, after a thousand histories and physicals, the physicals are pretty routine. Every history is fascinating. And so that's sort of how I got there. But writing was definitely not on the radar. I mean, I, you know, was interested in the hard sciences. I didn't pay attention in English. And this was such a labor for me to write. I mean, it's not something I do easily or well.

[00:07:20] I mean, I've learned I have to just rewrite everything about 10 times. And so this was very hard for me. There'll be no brother's keeper, too, or anything. I mean, I was driven by it. Just this is my experience over 40 years plus. I just have to write it down because we're getting things wrong. And that's the exact same stance that I had taken after residency was, you know, I'm not going to be some, you know, highly respected academician. And I'm not going to be working in research.

[00:07:49] How can I impact a broken system? Well, I can get on the airwaves, which I'm not comfortable doing. I mean, you know, it's not something that I want to be doing sitting here and having the camera on me and listen to my ideas. But at the same time, it was like, what can I do? How can I impact the system?

[00:08:09] I can get on here and I can speak in a way that is not overly scientific, that tries to reach the general public, the general person, so that we can then say this system has to change. You know, I've come around that sort of late because I did sort of enter the field thinking I could change things. I came in right as there was the shift from psychoanalysis to biological psychiatry. Osher versus Chestnut Lodge.

[00:08:38] I don't know if you're about that story where there was an internist who had serious depression. He was hospitalized in Chestnut Lodge, which is analytically based inpatient for a year or more and didn't get better. Then somebody put him on a tricyclic antidepressant and he got all better. And he sued the hell out of Chestnut Lodge, which is one of the last great analytic hospitals. And it put them out of business. And psychiatry got split into the biological versus psychological, which was such a shame.

[00:09:07] At that time, psychoanalysis was really treated more like a religion than a science. And I still believe there's a lot of very important ideas in it. But it just got treated like this dogmatic religion. I mean, I had supervised to tell me, do not medicate someone. And the other side, so I joined the psychopharmacologist. And there was, you know, medication was the answer to everything.

[00:09:30] Then some of the people, I mean, I talk about in my book, I got invited to a launch for Olanzapine. And I had been a coordinator for the Northern California VA, their Clozapine program. And so I was sort of knowledgeable about that. But it was just clear it was a sales job. They wanted me to be a huckster. It was so offensive that they wanted me to become a spokesperson.

[00:09:55] And then you see people like Nemrov and Biederman, these people who just sell their souls to make money and, you know, promote these things which may have a place, but they sell it like, you know, it's God's gift to the human body. And I've had seen so many failed promises in our field. It's just embarrassing that we oversell things.

[00:10:18] I think the best images that I've ever seen to help describe overconfidence and the problems associated with it is that Dunning-Kruger curve. You know, obviously everybody is an individual and there are levels to this. But I think some of the best psychopharmacologists that understand, you know, every little intricacy about what receptors are affected and what downstream effects those have.

[00:10:46] I think that can breed a certain overconfidence because... Oh, absolutely. When you get to three, four, five different medications and you take into account all that we don't know, which is... I like to sometimes ask people, what percent of what we know, what percent of the totality is that? Which is a very nebulous question, but there's so much that we don't know that... Well, the first day of medical school, it wasn't a psychiatrist. The guy got... He was actually a pathologist. He got up there.

[00:11:16] We've got good news and bad news as you embark on your medical career. This is our first day. He goes, first of all, half of what we teach you is wrong. That's the good news. The bad news is we don't know which half. You know, the receptors and the different... In the pharmacology, it's like the drunk who's looking for keys under the lamp. And why are you looking here? Well, I dropped them over here.

[00:11:40] But here's where the light's better that we know this, you know, receptor or we know this hormone. We know this transmitter. So we just keep looking at it. But it probably has all sorts of unknown effects that we don't. So we keep examining what we know, not what we don't know. We keep developing these me-too drugs because what's driving it is, well, if something similar works, this will work and we can sell it.

[00:12:09] Not can we find something better? And we bring out these drugs that are really no better than older ones. It's nice to have different options, but we spend so much money on the marketing of them and they cost us. And I think it's honestly embarrassing, like how many drugs we brought out that are really no better. I agree. I'm working right now on editing down a series on the new Alzheimer's drugs and just how disastrous they are in terms of their actual efficacy and safety.

[00:12:39] Was it aducanumab, the one that I've actually got a good friend, an ex-resident, who is heading up a company that's working on Alzheimer's drugs? He'd probably be willing to talk to you if you want. He's really got inside info. That'd be really interesting because I didn't realize it. Now, I saw Adjuhelm and I saw that the FDA scientific advisory panel voted 10 to 0 with one person abstaining against its approval. And then they approved it. Then they approved it anyway.

[00:13:06] And I'm like, well, what is the point of having a scientific advisory panel? What a black guy. It's conflicts of interest. Aaron Kesselheim resigns, Harvard psychiatrist, I believe, and a couple others resign. And then you start looking at the information that's come out in the last couple of years, mostly by science, about how there's so many manipulated images in the beta amyloid research, the protein misfolding drugs for Parkinson's.

[00:13:36] And it's like, what are we doing here? Does any of this, does any of it have any merit? And, you know, I don't want to go too far and say, oh, there's nothing in the beta amyloid theory, but it might be good to have your... Well, it's always so hard. I mean, we beat that idea to death. But then there was like the statins. For 10 years, they're saying, take these, take these, they'll make you... And there was no evidence that they actually extended life.

[00:14:02] Now it's come out that they do, and it takes a while, but, you know, you really have to approach this cautiously. And I mean, probably trillions of dollars we spend on MRI studies.

[00:14:13] And the ones like, I mentioned the one where the cynic, the dead salmon MRI study, where he put a dead salmon in an MRI machine and showed it pictures of different facial expressions and got it to show a statistically significant response to certain, you know, facial images, I think it was. And, I mean, a dead salmon is not going to show responses to human facial images, you know?

[00:14:43] But if you torture statistics enough, as the quote goes, they will talk. Like for me, this whole idea of having to give the power of a study before you can get funded. No, the whole idea is to figure out if it's powerful enough. If our drugs actually worked, we wouldn't need such sophisticated statistics. This whole takeover of statistics to prove things, I think, has been, you know, the P hacking.

[00:15:10] I have a mug, you've probably seen it, that my P values smaller than yours. I mean, if it's statistically important, it should be pretty obvious. You don't need to know these manipulations. That's one of the kind of overarching themes is, you know, if it's this obvious, like, for example, I had a patient on Monjoro, one of the GLP-1 agonists. Which has listed as a side effect, depression, suicidal ideation.

[00:15:38] And he comes to me and says, yeah, I just think it might be the drug. And I'm like, well, I don't really have any experience with this. But why don't we try, you know, coming off of the drug for a couple of months. And if he's still just as depressed, then we'll go back on the drug. The primary kind of symptom that I saw was apathy. You know, he couldn't care less what we did with his treatment. Comes off the drug, he's way less apathetic. And his primary care ends up starting him back on the drug a few months later at a lower dose.

[00:16:06] A month later, he comes back. He's extremely apathetic. Yet, I'm told that I should learn what the side effect profiles are and what drugs do based on a textbook. And I'm supposed to discount that personal experience on again, off again, see the result. Right. Which, again, I don't, doing that one time is not perfect evidence. But it's really direct evidence for me. And it's something that I can see play out.

[00:16:34] Well, I think we do overuse examples like that in our personal experience because they touch us so much. But you can't ignore them. What we used to do is colleagues would get together and talk. You didn't have a paid grand round where somebody is talking for a drug company or have conflicts of interest. You'd have somebody get up there and talk about their clinical experience and what seemed to work and whatnot. And people go, hey, me too. Or I've never seen that. It was not a money exchange. It was an idea exchange.

[00:17:04] It was a clinical experience exchange when people used to talk 30, 40 years ago. I went to a drug dinner one time when I was in residency. And it was with a very prominent name in the bipolar research community, Rakesh Jane. But he's talking about Raylar. Gets to a side effect slide. And it's like the risk of sexual side effects in the 500 in the placebo group was one out of 500.

[00:17:31] And the risk of sexual side effects in the Raylar group was zero out of 500. And I'm sitting there like, no, no. I'm like, you ask a thousand people who are drinking water or taking an aspirin. And if they have sexual side effects, there's going to be people who say that they are in both groups. This doesn't make any sense. Right. Right.

[00:17:54] It's examples like that where, to me, it's just so obvious of a way to try to manipulate what I'm learning. Well, that's a trouble when, I mean, the government has sort of gotten out of funding. So, so much is funded by industry. Or, you know, these things are written up by companies that specialize in ghostwriting papers. And, you know, again, you could torture statistics.

[00:18:21] Maybe they asked several different ways about sexual side effects and they chose one of them. They said you didn't have any sexual side effects, did you? Yeah, exactly. It's funny. I don't know how much of this you can put in the podcast, but I had a colleague who worked in my clinic. You know, he was training a psych postdoc. And he, when he had been at a prestigious institution and needed to do his dissertation,

[00:18:47] he was approached by the Lumosity people and said, hey, we want you to test whether our program improves cognition. And that's the one I talked about. I remember NPR used to give it away for the NPR stations. You know, if you donated enough money, you'd get Lumosity. And they would say proven, you know, brain training to prevent dementia. Anyway, his study was, you know, to run people through the program and see whether it improved cognition.

[00:19:17] And, you know, he didn't really find any great results. But what they did is they went around the country giving it to all sorts of psychology grad students. And they would just choose the ones that worked. The rest they would ignore. And they've since been sued, of course, because, you know, when you do these sort of training, you get better at the tasks they ask you, but they don't really seem to generalize. But, you know, they just pick the sites and the grad students whose results look good and ignored the rest.

[00:19:47] Yeah. And using, you know, surrogate markers like the Alzheimer's drugs and the example that dawned on me. And I really do. One of the reasons why I went into psychiatry, I think, is because I just love the way that our minds work. All these little intricacies, all these kind of what one of my patients calls random neuron firings, those sparks of imagination or idea. So I'm driving down the road and I just recorded this Alzheimer's two, two and a half hours with the pharmacist friend of mine.

[00:20:16] We got about a foot of snow in the last few days here in Louisville, Kentucky. So all the plows are out and I'm watching a plow go, you know, down the road. And I'm also driving on the now cleared road that now has more potholes than it had a couple of weeks ago. Yeah. And that is a great visual for how these beta amyloid removing drugs work.

[00:20:37] Yeah, they may scrape the snow away, but sometimes if that snow or ice is adhered to the pavement too tightly, when you go to scrape it away, you end up ripping off more than you planned on. Yeah, yeah, yeah. Which is why those drugs are associated with micro hemorrhages and brain swelling. Oh, wow. Yeah.

[00:21:02] Because when you have beta amyloid lining the blood vessel and you try to rip that off, well, yeah, you're going to get rid of it. But the more it's embedded into the blood vessel wall, you're either going to disrupt one of those three layers of the blood vessel or you're going to disrupt the whole thing. And you're going to get this tiny little bleed and you get that, you know, in 10 different areas of the brain. Interesting. Yeah. You've got major problems.

[00:21:26] Then you've got a drug that I think is going to, you know, if anybody ever does the actual morbidity, mortality and outcome data on those drugs, they're going to find that on average, they kill you two or three years earlier than you would have died because of the side effect profiles. Yeah. So something today about how prediction of how long people live with dementia really is based on how old they are. There's sort of a.

[00:21:56] So, yeah, that's a good example of it. Well, maybe you can give me a little bit of advice. So today I get to call my local hospital conglomerate and do my best to delay, deny and resubmit a ridiculous ER bill for some very basic services. Twenty five hundred for four lab draws for my two year old and a six hundred dollar chest X ray.

[00:22:20] When you're talking about making me pay twenty five X on that, it's just an egregious upcharge. But anyway, what would you recommend to patients who are dealing with just exorbitant medical bills? You know, those who have the time and ability doing what you do. But, you know, that's how it works. You get ground down and that's how the system is working.

[00:22:45] And people who are depressed or anxious or maybe psychotic, these are not people who are going to pursue, you know, fight the system. The system is OK that you won and got your bill reduced because the fact is most people won't. Americans spend literally I forget what the number is. It's like a billion hours on the phone with their health insurers, far more than they spend with their doctors.

[00:23:12] If you can make three or four people back down and even if one gets through, it's worth it in terms of dollars and cents. The more friction you can put in the system, they come out ahead. You know, it's like why medications for humans are something like five times more expensive for pets and just how the industry. But that's changing. I just took my dog in and it got a chest x-ray.

[00:23:38] Just, you know, one of these portable things in a vet clinic, which is now owned by a venture, you know, capital company or private equity. $450. It's completely absurd. But the money is there and people are investing in making money off of people's illness. I walked into a vet clinic, private equity owned and kind of has taken over as the emergency vet clinic in the city of Louisville.

[00:24:04] The minute you walk in the door, it's $1,000 put down if you want them to see your. Oh, the emergency clinic. Oh, yeah. More than that here. That happened. But, you know, it's my feeling is that mental health has just sort of been the model for this. Like this is happening all over in medicine and in veterinary medicine because it worked so well on the mentally ill.

[00:24:25] We've had restricted benefits, higher co-pays, all these blocks and barriers to getting your care in mental health for like now 30 years. And it's working so well that the rest of the medical industry has taken it over. People are I try to get in to see any specialist now or, you know, to get in to see your doc who I work for a conglomerate. They get booked back to back to back.

[00:24:52] And you're going to have to go to an urgent care or an emergency room if you need urgent care. The personal relationship where your doctor calls you back or fits you in just doesn't happen because they're not allowed to. They don't control their schedule. It's not in the venture capital business plan to leave the person an extra half hour to fit in emergencies. Why are so many private equity firms getting into these mental health systems?

[00:25:20] Health care in general is the largest and most profitable aspect of venture capital and private equity over the last several years. I think McKinsey came up with that. I don't know, but it's so lucrative. Now, that's changing a bit in the last year or two because I think there's starting to be some pushback. You know, it's like Willie Sutton. That's where the money is. They can make the money. It was just so ripe for the picking that they went where the money is. It's really a cynical look.

[00:25:50] But, you know, you've got your 401k invested in some fund. It's probably invested in a health care system. And the money that you're getting from your, you know, educational fund investment is making money off the health system that may close the hospital that might save your kid's life when they overdose by mistake. We don't we don't tie it together. From the patient perspective, but also from our perspective, how can we be part of the solution?

[00:26:20] You've got some intriguing ideas on that subject. You know, a sliding scale, private practice, not dealing with insurance, because if you don't take any insurance, typically that can go with, you know, not seeing severe mental illness and not treating that and leading to an even bigger disparity, you know, gas. Well, it's hard. I mean, that way, if you're going to do it and do it, try to do it ethically, it costs you money. I mean, I'm late in career and I'm I don't need to raise my kids anymore.

[00:26:49] And so I can make a lot less money. But people get angry when you don't take insurance. But I will flex enough so people can see me. I often use an example of I will charge somebody twice what they earn per hour to see me or something like that. And I also balance seeing, you know, some wealthy people, which then allows me to see some poorer people. And I justify it by saying on average, the community is getting better. I see some very, very ill people.

[00:27:18] But it's hard in practice. You know, they often have to have supportive families. I don't have, you know, a social worker on staff or a nurse who can, you know, take care of some administrative things for me. You have to pick and choose a bit. You know, being on an insurance panel is such a weird concept. Health insurance is not really insurance.

[00:27:42] Insurance is when a group of people band together and put in money so that if a devastating consequence like a house fire or, you know, a life insurance, a death happens. The group is supporting the individual that the disaster happens to. That's not health insurance. Health insurance. We spend all the time. Everybody needs health care.

[00:28:06] So all we've done is created this parasitic middleman who is making money off of taking more from us as we pay in and paying out less. Their whole business is antithetical to good health care. So, you know, it's like paying the mafia their protection racket. Pity if anything were to happen. Pity if you were to lose your health care. Why would you want to take part in that system?

[00:28:34] You know, I don't take any insurers, but I will certainly provide a bill for people. And I do take Medicare, which I found works pretty well. Every other developed country has worked out a single payer system. And I think that's what we need because we need an individual to decide what things are worth. And by the way, the AMA, I think, has screwed us with their RVU system. So, you know, surgery making 10 times what primary care does.

[00:29:02] And I think the same thing is happening in primary care. Now that happened in psychiatry. Why are we allowing these people to make basically health care decisions? Because health care is so expensive, even mental health care, that the insurers are deciding what they can pay and whether it should be allowed. We should have some sort of community-based, perhaps governmentally organized decision about what gets paid for and how much. Every other country does this. And we do it for Medicare. We did.

[00:29:31] Now there's Medicare Advantage, which is now turning out to be bilking us, too. And we have the VA system. These things work. And since we have these multiple different models, there's incentive that anybody who is sick to get punted into somebody else to pay for it. So that they have these battles going on. In health care, there are 16 workers for every one physician. 10 of those 16 do not do health care. They are just administrators.

[00:29:59] They do the business of medicine. Basically, if those 10 people were delivering health care instead of fighting over money, we would be more than twice as efficient. Which, by the way, is how much we spent more than twice in any other country. And why do we separate out diseases of the brain from the rest? We get put in some crappy side clinic. We have a different organization that's monitoring mental health benefits.

[00:30:28] It should be all the same. We've got the IMD, the Institute for Mental Disease Rule, which means that somebody on Medicaid can't get both mental health and physical care in the same institution. Or on the same day, why are we separating out mental health care? It should just be part of the body. Kaiser studies show that 60 to 90 percent of primary care visits are precipitated by psychosocial things. They may have a physical disease, but that's not what's bringing them in.

[00:30:58] There was a recent study looking at people with diabetes. And something like 70 percent of them wish their doctor had asked about what's going on with them behaviorally. Because it's a drag having diabetes. Why does our country separate out these things? In my training, going through primary care, not knowing a whole lot at the time, but seeing a patient come in and knowing at the time that, you know, I tried to entertain going into other fields.

[00:31:23] But I always just had such a strong pull towards psychology, psychiatry. But that diabetic would come in and they wouldn't even be asked whether or not they were taking their meds. It wouldn't even be asked. And so you end up raising the dose of a medication, again, secondary to a system that prioritizes quantity over quality.

[00:31:46] And that provider is rushed, you know, within 10 minutes, usually less than 10 minutes to see and evaluate and chart on that person. But you got all this medical knowledge, but that takes priority over a very basic question like, are you taking your medication? Absolutely. Because I don't want to make you hypoglycemic if you're not. And then I overdo it on your dosing.

[00:32:10] You know, it just seems like doctors and scientists have kind of lost hold on dictating what gets to be deemed as good science or good medicine. Well, it's also just not really collaborative, you know, to finding out what is in the patient's interest and what they want. You've got some surrogate goal, like in research, that if you really were on their side, like, how can I best help you?

[00:32:36] And they're going to hide things from us if they're worried that we won't approve. Yeah, I was really a little bit upset during the whole COVID outbreak that scientists weren't allowed to have scientific debates and discussions. No, no. About what they thought about a brand new vaccine that comes out. And it was just kind of forced down our throats that this is good for you and it will be helpful. And again, I don't know.

[00:33:06] Well, but not only that, you've got people with conflicts of interest were telling you you needed to get it. So, of course, people were cynical because the people telling you to get the vaccine were profiting from it. Right. But again, even just saying that, like, I feel comfortable with you saying it, but there's a certain amount of discomfort that I feel as we're even having this conversation. And I could even, I have the ability to go and X all of this out.

[00:33:33] But that is very telling in and of itself that we as a scientific community, whether or not you believe that there is worth in the something like that vaccine or not, we haven't been allowed to debate on these topics. It's like if we allow people to debate, we've been convinced that somehow we're going to propagate misinformation. Well, exactly. Because vaccines do have side effects and they do have problems. Now, look what's coming out about fluoride.

[00:34:00] You know, any intervention we do, including psychotherapy, can have bad outcomes. The fact is we want a reasoned person to say the chances are this intervention is much better for you than not. But not to say, you know, you got to get this or this is all good. Nothing is that certain. But if people don't feel like the person they're talking to, the person ordering them what to do as an advocate, they're not going to listen. And you can't blame them.

[00:34:28] I mean, there's been such a loss of trust in experts and including the medical field. And I don't blame people. No, no. That pendulum can swing too aggressively in the other direction where people do need help. They do need medical professionals, but they're not going to feel comfortable going to them, or at least some people won't. And I completely understand that.

[00:34:51] But I think that's particularly bad in psychiatry for several reasons that, you know, psychoanalysis grossly oversold what it could do. And then there was the biological revolution, which grossly oversold and had hopes to think what it could do. And you've got this cognitive behavioral revolution, which is 2,000 years old. It's evidence-based. That is great. It should be evidence-based, but this is somehow so much better than the others.

[00:35:18] We run from one magic bullet to another in a field that people are shamed. It's getting better. I think we've got people like Fetterman going public, and I think the young generation actually talking about their troubles. There's a little problem, I think, with social contagion that we need to worry about that people are actually talking about. But there's such shame around being a mental health patient.

[00:35:42] And that's why I think this whole client thing has taken off, because it's so threatening to be called a psychiatric patient. And people want to distance themselves from that because it's really, really shaming. But when you hide behind a euphemism like that, it basically validates and entrenches the stigma. You know, that which will not be named.

[00:36:06] And the LGBTQ community embraced the term queer or homosexual and gay and gained great recognition. Hiding behind a euphemism is not useful to us. I agree with you there. I was really glad to hear you bring up that point, because the places that I've seen client use the most is in corporate medicine. It's a business term, and they like it.

[00:36:30] Now, especially if you can get somebody defined as a client, they don't have rights and privileges that patients do of autonomy, confidentiality, and all these things. And you look at these businesses now are sharing personal health information widely, because it's for clients, not a patient. So one company just sells data to another, and that company, then there are clients, so they can share the information. And they do, and they sell it and use it.

[00:36:55] The HIPAA law, when it came into effect, and it was, oh, we're going to protect everybody's health information. Like, I need my health information, you know, under lock and key so nobody can ever, ever see it. My understanding is that they used to keep all the patient records in the lobby of the hospital. And the patient's family, the medical students could go review them. Because, I mean, yeah, if you're a celebrity or you have some vested interest in keeping your information private, I understand it.

[00:37:24] But it was sold as that. My understanding, correct me if I'm wrong, is that it really opened the doors for insurance to have all of our information. I don't think that was it. I mean, at least in my time talking about the last 40 years, it was clear that patient records were really private. I think it's when other things in the person delivering the care or the hospital delivering the care felt they owned the data. The other thing is, why would people want the data? Because they can make money off of it.

[00:37:53] It's driven, you follow the dollar. That you can make money by avoiding certain people and trying to recruit others who are wealthy and may want to pay for care. Why would somebody be interested in my health? Somebody who doesn't even know me. Right. Or if they could use that information to deny something or to charge you a higher rate because they saw in one, you know, health record from 15 years ago that you were a smoker. Right.

[00:38:22] You could understand why that makes sense as a business to exclude smokers from your life insurance policy. But if we're going to take care of a community and give people who've smoked health insurance, that doesn't benefit the community. They will need care someday. Is the goal of health care to make money or is it to make the community, everyone, relatively more healthy? And again, it's that much worse in mental health because people are so shamed and they pretend like that doesn't affect them.

[00:38:52] One out of two Americans know somebody who's died of a drug overdose. Yet we don't fund addiction medicine. There's so much shame around it. We pretend and act like it will never affect us. But it does. Who doesn't have an uncle, an aunt or brother or sibling or best friend's sibling who doesn't have a mental illness? We all know that, but we don't act like it.

[00:39:18] We hang on to our meager health insurance like clinging to the shards of a boat. Once it goes down, you want to hang on to what little you have. You brought up Medicare Advantage. I wonder if you saw the report that came out in the last few months about major insurance companies. UnitedHealth was one biggest company involved, but they had essentially siphoned about $50 billion for Medicare Advantage by labeling. By upcoding.

[00:39:46] So, you know, you have these ophthalmologists who are being reached out by these investigative journalists who are saying, hey, you're saying that the cataracts in your patient population are, you know, 30% diabetes related. And the incidence of that of all cataracts is like 2%. And the ophthalmologist is like, I didn't chart that. Like, I didn't make that diagnosis. Well, the insurance companies would send out their nurse practitioner, their whoever was involved.

[00:40:15] They go to the charts and they would add on what diagnoses they could. And so even though 98% of cataracts are just age related and there is no annual stipend that is given to the health insurance company for treating it, diabetic cataracts get about $3,000 a year per patient. And especially if you don't have to actually use that money to treat anything. In another realm, they were diagnosing patients with HIV that didn't have HIV. Yeah. Yeah.

[00:40:45] This is just that much worse in mental health because who's going to get out there or somebody with schizophrenia and fight over some billing thing? We've just been leading the pack in terms of these sleazy business practices. Yeah. Yeah. And like you said, the patient already feels stigmatized. So they're not chomping at the bit to put themselves out there and say, I am that person with schizophrenia who's being taken advantage of. Or the family. As if people have the time to do this.

[00:41:14] I mean, mental illness has always been marginalized. And that's something you can use to your advantage when you want to use sleazy billing practices. Yeah. Talk about insurance and the problems I have with dealing with it. But, you know, to work for an insurance company, to be on their panel, you don't really work for them. They don't pay your Medicare taxes. They don't pay into your Social Security. They don't pay your health insurance. You're like a gig worker with absolutely zero benefits.

[00:41:43] You don't negotiate the contract. Matter of fact, we'll often see a patient and you have no idea if they've met their deductible. You have no idea what their cap is. You have no idea what the reimbursement is. You have to take a contract which is entirely based on what the company wants. You have no input, no negotiation. Neither does the patient. Who would agree to that sort of deal? I mean, it's ludicrous. Yeah.

[00:42:12] And I mean, if you did have all that information, it probably would change your treatment in a lot of respects or in some cases. Of course it does. Yeah. Just to know how people are going to be affected financially. I mean, that is such an important factor. And in my own interactions with the health care system, providers or people working in health care will tell me, you know, just get your health care. Just get what you need to get done.

[00:42:37] But the reality is, you know, if I was spending a fifth of what I know, what the U.S. spends, if I was in the Czech Republic, that wouldn't be a factor. But these things follow us around and impact our health after that encounter. Of course. What is it? Like two thirds of people who are in bankruptcy blame that health care is their primary cause. There's a wonderful book from about 30 years ago, something called The Last Taboo. You have to get in by. It's wonderful.

[00:43:06] It's about people's view of money and health. And, I mean, we talk about people's bowel habits, their sex life, you know, their relationships. But we don't ask them, like how many of your patients, how much money do you make? Yet it's so important to our well-being, our sense of self, our comfort. But we won't talk about it. And that's why taking people on insurance or whatever is so comforting, they deal with it. It's not, that's not my wheelhouse.

[00:43:34] But it's so important for how people feel and their relationship with our patients and how they get better. We cop out on that, I think. Thanks again for watching and or listening. If you're passionate about the subjects that I discuss on the channel, do me a favor and like, comment, subscribe. Do whatever you can to make your voice heard that these are problems that must be addressed in our society.

[00:44:04] If you have any questions, comments, or concerns, I want to hear them. Feel free to reach out on social media or email us at renegadesyke at gmail.com. And if you'd like to be a guest of the show or you have a connection to somebody that you think would be a good guest, let us know. Thanks again for listening.