The patient holds a job as a clerk typist in a federal government office. He is a smart man with a college education and the ability to speak three languages. Still, Regier has to see him once a week for 15 to 20 minutes to keep track of medications, side effects and his overall condition, which can include mania, depression or psychosis.
The patient has no housing problem because his family has been able to give him the support he needs. This, in turn, makes it easier for him to keep his job. And that allows him to enjoy federal insurance benefits. Those supports make it more likely that he will keep his house.
However, if a patient loses any one of the three--the job, the benefits or the house--things can quickly spiral out of control.
In the private sector, Regier said, there tends to be a focus on patients who walk through the door and can afford care, and not as much attention to the system as a whole, but the public safety net of housing and services is crucial.
"Once you lose that job, you're vulnerable, even as a middle-class person," Regier said. Usually, private practitioners become aware of this only if it happens within their own families or with long-term patients who have a sudden demise. At that point, the psychiatrist must decide whether to continue with the patient. If the resources just aren't there, the patient may very well be out of luck.
It is a problem that all private practitioners worry about to some degree, Regier said. If family support disappears and a patient loses housing or a job or both, what can the clinician do?
Once a patient winds up on Medicaid, they have to struggle with a public-sector system that is under its own financial pressures. In Montgomery County, Md., for example, Medicaid services are provided through a fee-for-service reimbursement model in which categorical programs have been increasingly defunded.
That's when people start falling through the cracks, Regier said. If you don't have the categorical funding for case management in a fee-for-service managed care model, you've got a real problem. People begin missing their appointments, and no one is there to help manage their money. They miss their rent payments and wind up on the street.Commission Hearing