Some thoughts and questions:

1. A lot of the potential goodhart stuff like arguing that hospital stay isn't justified (and paying doctors to make this point for them) happens already. It is demonstrably a very cost-effective thing for insurance companies and HMOs to do. If the interventions don't work well, aren't a lot of these systems going to just continue the tradition of trying not to pay for stuff whenever possible?

2. Seems like a bond isn't that different from just getting premiums and from and paying for a patient that you can't just drop when they become a poor investment. Are bonds going to change things enough that now it makes sense to invest a lot in R&D to test and implement exactly what works, vs. just be as big a cheapskate you can get away with?

3. Not all first episode psychosis the same. A high strung executive who has an income and a supportive spouse but has an episode of mania while dealing with insomnia is probably going to cost much less than the kid who develops severe psychosis before age 15. How do you avoid the problem that various people will have bonds of clearly different value? ACA already means you can't refuse for poor prognosis, but if the whole point is abandoning public insurer fairness requirements wouldn't fairness be a problem? And presumably if insurers or other buyers refuse the bad investment, then medicaid is just stuck with the bills for the tough cases anyway.

You could go for a kind of auction system which could be interesting, but might take a lot to get off the ground. If the solution is a big company buying bonds for a bunch of patients together, that's already basically an HMO or managed care medicaid. Then the bet is basically can a company do better than medicaid at managing these patients. This is basically medicare advantage, right?

4. Medicaid footing the bill for almost all the severe patients in the end means that they already capitated and have incentives to minimize costs and do so through a number of instruments like paying caregivers, paying social workers for house calls and home check-ins, PHPs after a crisis and wrap-around services for heavy utilizers. They seem to be trying a lot of things, why not just pitch any effective and cost-saving measures directly to them? The fee-for-service isn't a great model especially for hospitalization, but the payments are already low compared to other areas of medicine and it's not like the mental health industry needs to create artificial demand except in edge cases, there is plenty as is!

5. Physician experts and legal issues. Are these bonds supposed to get exempt from existing standards of care and that's how they save costs? Presumably any new company would have to provide the same resources as available existing ones and failure to follow the expert recommendation could cost them in court in case of a negative outcome. Forfeiting all the bond income in case of death is an incentive to keep patients healthy but would place a lot of risk on the bondholder and wouldn't save you from getting sued regardless. Then it's trying to change the whole system again, and because it's hard to tell what works here are going to be a lot more hurdles in your way including professional organizations.

6. If no normal standards of care, what is the replacement? Since from what I was reading this plan looks to save on cost and preserve life, but doesn't specify anything else. For some patients, it would undoubtably be cost-saving and life-preserving to be very paternalistic and involuntary institutionalize. Once institutionalized, you wouldn't have any incentives to keep the experience nice beyond whatever prevents the next hospitalization. Are we okay with going back to this? What about other kinds of potentially coercive stuff like offering money to patients or family members to eg get on medications or off substances and all the problems that that creates? And even an org eg paying for rent could be incentive for patients to purposely get themselves into this system similar how people game the disability system or VA.

I think a lot of the reason you don't see more change is:

1. it's really hard to tell what works and most interventions don't work great

2. A lot of the stuff that doesn't work well is there because of law

3. The things that may work well may only work in certain circumstance and often very difficult to scale cost-efficiently

4. The patients are broke

5. the systems are basically broke too and often short-staffed and undertrained

So often we end up defaulting to standard of care and then don't fund it well because it doesn't work very well so why would we?

National health systems in other countries, The VA, medicaid, and big HMOs the US are already capitated and incentivized to bring down costs while ensuring customer health and satisfaction while working within the standards of care. They are already doing a lot more than most people probably realize to reduce hospitalizations and bring down costs. And because they are big healthcare systems with bigger budgets, more risk tolerance, longitudinal relationships, they are much better positioned to try and innovate than the smaller organizations. They do research and test the efficacy of their interventions, although I can see an argument that they are slowed down by their bloat and the administrative incentives you mentioned.

The aspect I like the best is getting people with FEP into a comprehensive care system right away. It's too easy for people to fall through the cracks and end up in scenario C more often than if they had great followup and more assistance at getting other help. Better surveillance for FEP and followup is likely something that a lot of these companies could save resources by investing in in the long run.

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Hey! I love this comment; it brings in a bunch of stuff I didn't know, and objections that make sense. Wanna have a call? jess@psychcrisis.org or https://calendly.com/jessicawatsonmiller

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Sep 7, 2023Liked by Jessica Ocean

Thank you! Not used to receiving positive feedback especially when writing somewhat critically. I definitely have a lot of interest in this space and what you are doing. Scheduled a meeting for next Tuesday

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> However, the best psychiatrists, successfully recovered patients, and many academics agree that one initial psychotic crisis only creates a small direct increase in the chance of a crisis occurring again, and that much more of the suffering and later mental health challenge that occurs after a crisis occurs because their temporary disability from the initial crisis causes a cascade of practical problems or losses of trust in their life that become too overwhelming to handle and create a permanent loss of capacity which in turn makes further crises more likely.

> This model implies that the response to the first crisis, both allowing enough time for recovery, and creating resilience in the person’s life to protect against damage from future crises, has an outsized importance when it comes to helping someone at risk of serious psychiatric disability avoid that outcome.

Catching after the first crisis is the best, but there are lots of second best options too. Early psychosis programs have inconsistent eligibility criteria across states and countries. And the boundary is often discrete. If you are under 25 you are in, if you are over 25 you are out. Yet that person on the borderline is just as likely to benefit at say 27 or 30 and improve lifetime costs and outcomes.

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