How Done. makes quality ADHD care accessible, reliable and affordable.
My name is Dr. David Brody, and I am Clinical President of Done., a telehealth company that has been engaged in the online diagnosis and treatment of adult ADHD for nearly three years. Our mission remains unchanged: make ADHD care accessible, reliable, and affordable.
It’s no secret the American healthcare system is often dysfunctional. Indeed, this dysfunction is in large part responsible for the rise of telehealth sites, many of which have sprung up in the past few years to fill any respective void. They strive to satisfy multiple serious medical needs, and I wish them all success.
In this post, I will illustrate how Done. has shaped its platform to help patients optimally deal with ADHD by providing relief from the effects of the antiquated, cumbersome, and largely uncaring “system” of “care” described above. I will focus on the three key domains set forth in our mission statement.
It starts with accessibility
Accessibility is the Achilles heel of the current healthcare “system.” This is because private insurance, the “gold standard” of the health safety net in this country, is accessible only to people who have been full-time employees of a medium-to-large company for a significantly lengthy time. This criterion is an arbitrary anachronism that resulted from an accident of history held over to the present day because it continues to benefit certain parties.
Only two-thirds of Americans have private insurance. This is the best coverage available in this country, as it gives1 access to care of superior quality and convenience. But the sick person who relies on private insurance for diagnosis and/or treatment of a psychiatric disorder is always required to pay a significant deductible and copayment, in addition to the also-significant payroll deduction required to get the insurance in the first place.
Even with the coverage provided by Medicare, Medicaid or military insurance, that still leaves 33 million people without healthcare coverage. So where do they receive help?
ADHD is actually one of the many factors that increase the probability of a patient turning up in an emergency room with a life-threatening cardiac event. If ADHD and other psychiatric problems that have harmful cardiac effects could be managed successfully, then the burden on emergency services would be significantly reduced. Unfortunately, there is an obvious catch; psychiatric disorders can only be successfully managed in the system of outpatient care, the very system to which access is denied for the uninsured.
Simply receiving access means a brighter future
Diagnosis and treatment of adult ADHD requires a qualified specialist in psychiatry. The bare-bones medical care available for the uninsured in the emergency room does not include psychiatric specialists or the capacity for follow-ups. Thus, the uninsured are excluded from ADHD care unless they can afford to pay out of pocket. Because those with ADHD are more likely to suffer economically disadvantaged circumstances, the very segment of the population suffering the most from ADHD is unable to access care. Furthermore, the lack of outpatient care for psychiatric disorders magnifies the already increased risk of excess mortality the uninsured face, by adding the serious physical complications of ADHD to the effects of socioeconomic deprivation.
(Adult ADHD Sufferers Face Lost Income, Jobs/Average Loss of $10,000 a Year, More for Professionals, By Charlene Laino/ Medically Reviewed by Michael W. Smith, MD on May 25, 2005 FROM THE WEBMD ARCHIVES)
Those with Medicare and/or Medicaid hardly fare better.
The vast preponderance of psychiatric treatment of the Medicare/Medicaid population occurs in “community mental health centers.” Although they are officially “outpatient clinics” in terms of the severity of illness, the community mental health center is in actuality analogous to an urgent care center or emergency room. This is because the typical outpatient physical clinic treats people who are ill, but not in acute danger of their lives. In dramatic contrast, community mental health centers must manage the most severe disorders, predominantly psychosis, bipolar disorders, and life-threatening major depressive disorders.
The false conception of ADHD found in the media and thus in the popular imagination features an absurdly mild illness, hardly more than an annoyance, differing only from garden-variety absentmindedness to a minor degree. The condition causes major impairment of psychosocial functions plus a significant risk of mortality from suicide or accidents. Sadly, some medical and psychiatric professionals either have inadequate knowledge of ADHD or ignore evidence of its severity in response to political pressure, as the medical leadership of certain clinics has implemented a blanket refusal to treat ADHD, claiming that it is not a “serious mental disorder.” Such policies are simply add-on manifestations of the stigma inflicted on ADHD patients, in this case particularly reprehensible because they are perpetrated by health professionals.
Affordability while still maintaining quality
I have painted a bleak picture of the prospects for adequate ADHD for the one-third of the American population without private health insurance and who simply cannot access proper ADHD care. The reader might hope that the remaining two-thirds can at least obtain adequate, if not excellent, care. I am sad to report that this is not the case.
There are no equivalents of community mental health centers to serve the two-thirds of Americans with private insurance. General health clinics accepting private insurance do not maintain psychiatric specialists on staff. Thus, an ADHD sufferer with private insurance has no choice but to turn to specialists in private practice.
Because insurance discriminates against “mental” illness, the copayments and deductible for care from a psychiatric specialist are sure to be many times higher than they would be to manage a physical illness. To make matters worse, there is an acute shortage of psychiatric specialists in this country, resulting in wait times of 3-6 months or more for an initial appointment. Thus, even with possession of “Mercedes” insurance, care for ADHD is anything but luxurious.
“Frustrating” is too mild a description for the inability to arrange ADHD care expeditiously. As mentioned above, ADHD carries with it an increased risk of death by accident or suicide, and a guarantee of poor functioning. A better word might be “debilitating.”
So how does Done.’s platform and organization alleviate the dire circumstances faced by an ADHD patient in the dysfunctional health care system of the U.S. and make the critically needed treatment happen nonetheless?
In terms of accessibility, Done. is accessible to anyone who can pay for a monthly subscription, the cost of which is probably 1/2 or less of the cost of private care from a psychiatric specialist. I freely admit there remain a significant number of people for whom the cost of a Done subscription is still prohibitive. In my role as clinical president of Done, I am working with our founder and our investor groups to initiate a “sliding-scale” fee to enable all to benefit from our services.
The issue of the long wait time for evaluation and treatment is essentially eliminated by Done. We are continually expanding, and thus continually expanding our panels of psychiatric mental health nurse practitioners and of board-certified psychiatrists. For areas in which wait times are relatively long, we are prioritizing the recruitment of providers licensed in those states.
Reliability infuses greater trust
Reliable care and continuous care are synonymous. Breakdowns in care occur when continuity is interrupted. The most common cause of a breakdown is unavailability of the patient’s long-term clinician.
Such harmful interruptions happen with depressing regularity in the community mental health clinics mentioned above, as these clinics have a high turnover, including many trainees who leave as soon as their practicum is completed.
Maintenance of continuity of care is Done's cardinal principle. This commitment starts with the initial evaluation. Barring unforeseen circumstances, the clinician performing that assessment will continue treating that patient as long as the patient continues with Done.
The clinician who first evaluates the patient has an insuperable advantage over others, as she or he has gone into the depth necessary to formulate an effective treatment plan. They often have the additional advantage of having examined the patient in an untreated or undertreated state, enabling a more vivid narrative of treatment, as such knowledge throws the changes that occur with treatment into sharper relief.
Generally, when symptoms remain worse than merely annoying, Done patients are seen monthly. At the level of monthly frequency, the 15 minute follow up sessions constitute brief supportive individual psychotherapy, a modality which has been shown to synergize with medication to provide even more effective ADHD treatment.
Once symptoms are stabilized at a level truly acceptable to the patient, the session frequency may be reduced to four times per year.
Clinicians are encouraged by Done to take vacations sufficient to maintain healthy life-work balance. Being human, they may of course suffer illness, or even retire or leave the platform. How these inevitable circumstances are handled is a measure of an organization’s success in providing continuity of care.
Done.'s goal is to institute a system in which any absence is covered. For foreseeable absences, in a truly “patient-centric” environment, they will be covered by a colleague to whom all relevant information has already been transmitted. In the cases of unforeseen unavailability, myself and the three other members of the clinical leadership team will provide prescriptions or other needed assistance within 24 hours. For nonclinical concerns, our superb care team is ready to assist, again with an excellent track record of fulfilling calls within 24 hours.
Accessibility, affordability and reliability are three pillars all telehealth platforms must follow if they place patients first. Done., which began with a patient-first philosophy and designed its interface on that foundation, is uniquely qualified to provide accessible, affordable and reliable care to alleviate the underrecognized and undertreated burden of ADHD.
1 (“Then, in 1943, the Internal Revenue Service decided that employer-based health insurance should be exempt from taxation. This made it cheaper to get health insurance through a job than by other means. After World War II, Europe was devastated. As countries began to regroup and decide how they might provide health care to their citizens, often government was the only entity capable of doing so, with businesses and economies in ruin. The United States was in a completely different situation. Its economy was booming, and industry was more than happy to provide health care. This didn’t stop President Truman from considering and promoting a national health care system in 1945. This idea had a fair amount of public support, but business, in the form of the Chamber of Commerce, opposed it. So did the American Hospital Association and American Medical Association. Even many unions did, having spent so much political capital fighting for insurance benefits for their members. Confronted by such opposition from all sides, national health insurance failed — for not the first or last time.”- By Aaron E. Carroll, The New York Times, Sept. 5, 2017).