US Medical Student Health Insurance Coverage for Mental Health Treatment After the COVID-19 Pandemic.

This quality improvement study aims to update the existing literature and evaluate current mental health insurance coverage for medical students in the postpandemic environment.

Availability of Outpatient Child Psychiatric Care During COVID-19: A Simulated-Patient Study in Three U.S. Cities.

OBJECTIVE: In this study, the authors sought to ascertain the availability of outpatient child psychiatric appointments in three U.S. cities. METHODS: Using a simulated-patient methodology, investigators called 322 psychiatrists who were listed in a major insurer's database for three U.S. cities, and they attempted to make appointments for a child with three payment types: Blue Cross-Blue Shield, Medicaid, and self-pay. RESULTS: Initial appointments were available 11% of the time, and it was most difficult to obtain an appointment under Medicaid coverage. Nineteen percent of phone numbers were wrong, and 25% of psychiatrists were not accepting new patients. CONCLUSIONS: These results are concerning given the current mental health crisis among youths and suggest the need for more psychiatrists, higher reimbursement rates for psychiatric services, and continued efforts to increase access to care. This study also highlights the need for insurance companies to maintain accurate information in their databases.

A Pregnant Pause: System-Level Barriers to Perinatal Mental Health Care.

Perinatal mood and anxiety disorders, defined as mood and anxiety disorders during pregnancy and the year following birth, affect one in five pregnant and postpartum individuals in the United States and are associated with substantial morbidity and mortality for both pregnant individuals and their infants. Despite this tremendous prevalence and associated disease burden, the overwhelming majority of those affected do not receive treatment. Although prior research has identified several patient-level barriers to effective treatment, the contributions of system-level factors have been underappreciated. We present a pilot study using a simulated patient approach to describe the accessibility and affordability of mental health care through the 18 clinics affiliated with U.S. reproductive psychiatry fellowship programs. Based on our experience, a prospective patient seeking care from these 18 clinics without a prior referral would only have been successful half of the time-and even then may have to wait as long as 2 months for an initial appointment. These data underscore the need for clinicians, public health professionals, and institutions to address system-level barriers that undermine effective referrals for care, including implementing "warm-handoffs" to mental health providers and ending practices that restrict appointments to existing patients within a health care system. They also reinforce the importance of contemporary federal policy efforts to address maternal health, particularly among low-income and racially minoritized communities. Key policies include expanding postpartum insurance coverage, which plays a critical role in reducing insurance disruptions that can undermine the accessibility of mental health care and other vital health services.

Medical futility is commonly encountered in small animal clinical practice.

OBJECTIVE: To document veterinarians' perceptions and understanding of medical futility and determine the frequency with which medical futility occurs in small animal practice. SAMPLE: 477 veterinarians in small animal general and specialty veterinary practice. PROCEDURES: A cross-sectional study was performed with a 25-question, web-based, confidential, anonymous survey distributed through various professional veterinary specialty associations. RESULTS: Nearly all respondents (469/474 [99.0%]) believed that futile care occurs in veterinary medicine, and 42.4% (201/474) felt it occurred commonly (> 6 times/y). A similar percentage (471/475 [99.2%]) reported encountering futile care within their careers, and 85.0% (402/476) reported encountering it within the past year. A majority (293/477 [61.4%]) reported witnessing futile care occurring in both inpatient and outpatient settings. Most respondents disagreed or strongly disagreed (320/463 [69.1%]) with a statement that providing futile care is always wrong, and only 38 (8.2%) agreed or strongly agreed. Over 70% (329/464 [70.9%]) of respondents agreed that there are situations in which provision of futile care is appropriate. CLINICAL RELEVANCE: The importance of reaching a consensus definition for medical futility in veterinary medicine is evident given the frequency with which such care is being provided. Most small animal specialist veterinarians will encounter futile care, and the establishment of an ethical framework to navigate questions surrounding medical futility may help reduce moral distress.

Against Our Instincts: Decriminalization of Buprenorphine.

The rate of overdose deaths has increased dramatically over the past 2 decades. Recently, efforts have been made to expand access to medications for opioid use disorder, such as buprenorphine, by removing X-waiver training requirements. However, relieving such barriers has also raised concern about increasing diversion rates for buprenorphine use, defined as the use of buprenorphine for some purpose or by someone other than it was originally intended. Historically, diversion has been addressed through the criminalization of buprenorphine possession without a prescription. We argue that while buprenorphine diversion is not to be condoned, the benefits of such actions greatly outweigh the harms. Thus, criminalization of diverted buprenorphine represents a dangerous and wasteful response that threatens the progress made through expanded access to this lifesaving medication.

Race, Power, and COVID-19: A Call for Advocacy within Bioethics.

Events in 2020 have sparked a reimagination of how both individuals and institutions should consider race, power, health, and marginalization in society. In a response to these developments, we examine the current and past limitations of the ways in which bioethicists have considered race and, more generally, discourses of marginalization. We argue that the foundational principle of justice necessitates that bioethics, as an institution, maintain an active voice against systemic injustice. To carry out this charge, bioethics as a field should promote alternative narratives-"counter storytelling"-to the mainstream voices that have traditionally been heard and accepted, largely without opposition. Additionally, we engage with both Post-Colonial and Critical Race Theory, which we believe are important tools for bioethics in pursuit of equity. Ultimately, we advocate for a proactive form of bioethics that actively resists and denounces injustice and which considers a much wider variety of voices about justice than bioethics has historically considered.

Availability of Buprenorphine Treatment in the 10 States With the Highest Drug Overdose Death Rates in the United States.

OBJECTIVE: The objective of this study was to assess the accuracy of the Substance Abuse and Mental Health Services Administration (SAMHSA) database for patients who use it to seek buprenorphine treatment. DESIGN AND MEASUREMENTS: Buprenorphine providers within a 25-mile radius of the county with the highest drug-related death rates within the 10 states with the highest drug-related death rates were identified and called to determine whether the provider worked there, prescribed buprenorphine, accepted insurance, had appointments, or charged for visits. RESULTS: The number of providers listed in each county ranged from 1 to 166, with 5 counties having <10 providers. In 3 counties no appointments were obtained, and another 3 counties had ≤3 providers with availability. Of the 505 providers listed, 355 providers (70.3%) were reached, 310 (61.4%) of the 505 listings were correct numbers, and 195 (38.6%) of the 505 providers in the listings provided buprenorphine. Of the 173 clinics that provided buprenorphine and were asked about insurance, 131 (75.7%) accepted insurance. Of the 167 clinics that provided buprenorphine and were asked about Medicaid, 105 (62.9%) accepted it. Wait times for appointments ranged from 1 to 120 days, with an average of 16.8 days for those that had a waitlist. Among the 39 providers who reported out-of-pocket costs, the average cost was $231 (range: $90 to $600). One hundred forty of the 505 providers listed in the database had appointments available (27.7%). Three hundred sixty-five of the 505 providers did not have appointments available (72.3%) for various reasons, including the fact that 120 providers (32.9% of the 365 providers) could not be reached, and 137 of the numbers (37.5% of the 365 listed numbers) were wrong. Other reasons appointments could not be obtained included the fact that providers did not treat outpatients, were not accepting new patients, were out of office, or required a referral. CONCLUSION: Although the SAMHSA buprenorphine practitioner locator is used by patients and providers to locate treatment options, only a small portion of clinicians in the database ultimately offered initial appointments, implying that the database is only marginally useful for patients.

How Ought Health Care Be Allocated? Two Proposals.

Two thinkers have crafted visions of how they believe health-care resources ought to be allocated if there were universal health-care coverage in the United States. One is The Ends of Human Life (1994), in which Ezekiel Emanuel proposes to base resource allocation on community preferences. More recently, Charlene Galarneau has written Communities of Health Care Justice (2016), partly in response to Emanuel's earlier work. Both thinkers center their visions of just health care on communities, albeit differently structured from one another. This essay examines the similarities and differences in their proposals for resource allocation and addresses questions that arise from their proposals, such as: What are the advantages of their community-based approaches compared with more universal, nationalized options? What might prevent communities from excluding certain individuals from active participation? And finally, does positing active engagement in a community, all by itself, guarantee that justice and fairness will be served? The essay concludes that although community allocation of health services has some desirable elements, allocating resources in a centralized, national manner would be more efficient, practical, and more likely to prevent bias and discrimination against those at the margins of their communities.

Psychiatric Resident Participation in an Asylum Clinic: a Single-Institutional Experience.

OBJECTIVE: This study describes the experiences of adult psychiatry residents working in an established faculty-led asylum clinic within a community-based, academic residency program at the Cambridge Health Alliance. METHODS: Eighteen psychiatry residents who participated in the asylum clinic were sent electronic surveys asking about their background and experience. Respondents' responses were collected anonymously. RESULTS: Sixteen out of 18 (89%) trainees responded. Thirteen respondents had a personal history with immigration. Fifty-three percent of residents wanted to utilize their professional standing to advance moral good. Writing up affidavits was noted to be challenging by nine (60%) of 15 trainees. Ninety-four percent (15/16) of trainees noted that they would be willing to perform future evaluations. Most noted that performing evaluations had a significant impact on their clinical practice and their conceptualization of their own roles as psychiatrists. CONCLUSIONS: Participating in asylum evaluations impacts residents' sense of themselves as psychiatrists and expands their views about psychiatrists' roles.

How broad are state physician health program descriptions of physician impairment?

BACKGROUND: Physician health program websites in 23 states provide many descriptions of possible physician impairment. This study sought to determine whether these descriptions are so broad that almost everyone might potentially be suspected of being impaired given these descriptions. METHODS: The authors randomly selected 25 descriptions of impairment and then presented them anonymously online to members of the general population in full-time employment through Amazon's Mechanical Turk (N = 199). Half of the respondents randomly received a narrowly worded version, and half received a broadly worded version of the survey questions. RESULTS: In the narrowly worded version of the survey, 70.9% of respondents endorsed at least one description of impairment, and 59.2% endorsed more than one. In the broadly phrased version, 96.9% endorsed at least one description, and 95.8% endorsed more than one. These respondents endorsed a median of 10 out of 25 (40%) descriptions. CONCLUSIONS: These findings call into question whether these descriptions really identify persons with poor performance or who pose a high risk of substantial, imminent harm to self or others in the workplace. They also demonstrate the extent to which these descriptions could potentially be misapplied and brand almost anyone as impaired.

Do state physician health programs encourage referrals that violate the Americans with Disabilities Act?

The websites of many physician health programs provide lists describing signs of impairment or indications to refer physician-employees for evaluation and possible treatment. This study aimed (1) to determine how many of these descriptions likely provide physicians' employers with sufficient evidence to legally request mental health examinations under the general regulations of the Americans with Disabilities Act (ADA); and (2) to find out who they described. The authors applied US Equal Employment Opportunity Commission guidance documents and sought expert legal advice to evaluate the descriptions for their consistency with the ADA. They used directed content analysis to review and code these descriptions into categories. Very few, if any, of the 571 descriptions appeared to provide sufficient evidence for employers to request an examination under the ADA. About 14%, however, could refer to physicians attempting to defend themselves, assert their ADA rights, or otherwise complain about the hospital; and 27% either described physicians who complain or else had discriminatory effects in one of several different ways. Leaders within the medical field should ensure that their policies and state laws pertaining to physician impairment comply with and incorporate the language of the ADA. They should also reevaluate the functions of these policies, laws, and physician health programs, and the implications for patient safety, physician wellness, suicide, and other important issues.