American Psychiatric Association Honors Dorothea Dix With First Posthumous Fellowship

Dorothea Lynde Dix (1802-1887) devoted her life to improving the care of impoverished persons with mental illness by creating institutions that became centers of psychiatric treatment, research, and education. St. Elizabeths Hospital, founded in 1855 in Washington, D.C., is one of these.

In recognition of Dix's central role in advocacy for humane care and development of the medical specialty of psychiatry and in honor of the 150th birthday of St. Elizabeths, the American Psychiatric Association (APA) has made Dorothea Dix an honorary fellow of the association, the first such fellowship awarded posthumously.

APA President Michelle Riba, M.D., will present the award to Joy Holland, R.N., M.H.A., current administrator of St. Elizabeths Hospital during a banquet celebrating the hospital's sesquicentennial anniversary on May 6, 2005. The banquet is the closing event of a two-day educational symposium, "The Role of the Public Psychiatric Hospital in the 21st Century," to be held at the Washington Convention Center in Washington, D.C., on May 5 and 6, 2005.

St. Elizabeths Hospital, which was originally called the Government Hospital for the Insane, was created as a direct result of Dix's efforts. She was personally responsible for obtaining funding and land from the U.S. Senate for this first and only federal psychiatric hospital. Since 1987 St. Elizabeths has been operated by the Department of Mental Health of the District of Columbia and is the District's only public psychiatric hospital.

Dorothea Dix was a pivotal figure in the history of psychiatry in the United States. Her contributions were recognized in the journal Mental Hospitals, a precursor of Psychiatric Services, in a special issue commemorating the 100th anniversary of St. Elizabeths in 1955. Winfred Overholser, M.D., the fifth superintendent of the hospital and a president of APA, edited the issue and dedicated it to Dix, "the stalwart citizen who aroused the public conscience, thus making possible the real beginning of hospital psychiatry in America."

Dix led the asylum movement in the United States, which became a powerful force for social reform. Asylums were considered essential in the treatment of the mentally ill population, because, when correctly designed and run, they were believed to provide an environment in which afflicted patients could be treated and even cured. In 1841 a total of 13 asylums existed in the United States. In 1880 the number had increased to 123. Dix founded or helped to establish 32 of these asylums and considered and referred to them as her children.

Dix also played a critical role in the development of psychiatry as a medical specialty. The physicians who managed the asylums developed a professional identity as providers of treatment for mental disorders. Thirteen of these men founded the Association of Medical Superintendents of American Institutions for the Insane (AMSAII) in 1844, which was APA's precursor organization. After 1845 membership in the association soared as the proliferation of state-funded mental institutions created the need for new superintendents and asylum doctors. AMSAII also depended on Dix—she was the organization's devoted unpaid lobbyist in state capitals and in Washington. In a tribute at the time of her death, Charles Nichols, M.D., St. Elizabeths' first superintendent and later president of AMSAII, called Dix "the most remarkable woman that the New World has yet produced."

Sadly, except for some of her namesake hospitals, Dix has disappeared from sight in the 21st century. Unlike her contemporaries Clara Barton and Florence Nightingale, Dix never captured the public's eye or admiration. The asylums have fallen into disrepute and many, like St. Elizabeths, into disrepair. Some no longer exist.

Dix's mission to provide "the most humane care and enlightened curative treatment of the insane" remains a goal that we are still striving to attain. Some 150 years after the founding of St. Elizabeths, the problems of providing humane care to impoverished mentally ill individuals, many of whom are again living on the streets, remain unsolved.

For more information about St. Elizabeths Hospital's sesquicentennial educational symposium, "The Role of the Psychiatric Hospital in the 21st Century," to be held on May 5 and 6, contact Gary McMillan, director of the library and archives at APA at 703-907-8648 or go to www.seh150.org.

Liza H. Gold, M.D.

Kaiser Commission Report Addresses Challenges of Enrolling "Dual Eligibles" in New Medicare Drug Plans

On January 1, 2006, Medicaid drug coverage will end for six million people with low incomes who receive both Medicare and Medicaid benefits. The so-called "dual eligibles" must join one of the new private drug plans established by the Medicare Prescription Drug, Improvement and Modernization Act of 2003, and the enrollment window is very short—just six weeks, beginning November 15, 2005. People with dual eligibility often face serious health challenges, such as diabetes or severe mental illness, and rely heavily on medications. The Kaiser Commission on Medicaid and the Uninsured has released an issue paper that describes the challenges of managing this large and rapid transition and identifies "risk points" that if addressed now could minimize disruptions in drug coverage. The paper is accompanied by two additional documents that report findings from focus groups held in late 2004—five groups of dual-eligible beneficiaries and one group of 14 state Medicaid officials.

Automatic enrollment is a particularly problematic issue, according to the paper. Medicare beneficiaries must be informed of the plans available in their locales no later than October 15, 2005. Except for the dual-eligible group, beneficiaries will have six months—from November 15, 2005, until May 15, 2006—to join a plan. The legislation addresses the risk of coverage loss due to the short enrollment period by requiring that any dual-eligible individual who does not join a plan by January 1, 2006, be automatically assigned to one on a random basis.

To select an appropriate plan, the Kaiser paper notes, an individual must understand how the new Medicare drug benefit works, how the available private plans operate, which drugs are available through which plans (some plan formularies may not offer a needed drug), how to obtain drugs, and what to do when the formulary is not adequate. The selection process can pose significant barriers, especially for people with cognitive disabilities. Although automatic enrollment is necessary to ensure continued drug coverage, it does nothing to remove these barriers, the paper points out.

The dual-eligible group will need targeted outreach and education. Rules proposed in August 2004 for implementing the Medicare drug plan do call for special outreach to low-income beneficiaries, the Kaiser paper notes, but provide no details on how those with dual eligibility will receive enrollment assistance. The federal Center for Medicare and Medicaid Services should undertake a multipronged effort that includes targeted outreach programs; strong preenrollment education programs; multiple methods of education, including mailings, telephone calls, and group presentations; and individual counseling about choosing a plan. Lessons about increasing voluntary enrollment that states have learned in implementing Medicaid managed care programs did not find their way into the proposed rules, according to the Kaiser paper. States found that hiring private companies to conduct outreach, education, and counseling was effective, especially in countering the biased marketing information sent to beneficiaries by private plans—a situation that is already beginning to occur as the Medicare drug plans compete for enrollees.

Participants in the Kaiser dual-eligible focus groups feared that they would receive literature from different plans over the course of many weeks, making it difficult to choose in an informed way. They hoped that the states would compile a single booklet presenting information about all available plans in simple language and in a standardized format. Participants made it clear that they do not see themselves as "dual eligibles," and for outreach efforts they suggested use of the phrase "people who receive both Medicaid and Medicare." Many said that they would seek help in choosing a plan from their physician or pharmacist and that efforts to "get the word out" about the Medicare plans should target these groups. It was also clear from the focus groups that the vast majority of dual-eligible beneficiaries do not use the Internet and that this was not a good approach to outreach or education.

Another problem with the proposed implementation rules, according to the Kaiser paper, is that they do not specify whether the states or the federal government will carry out the automatic enrollment process, and the paper presents reasons for and against state responsibility and federal responsibility. For example, because the size of "clawback" payments that a state must send to the federal government increases with the number of beneficiaries enrolled in the drug plans, there is a fiscal incentive for states to keep enrollment low. With few exceptions, the state Medicaid officials in the Kaiser focus group thought that states should not conduct automatic enrollment, even though they believed that states were in the best position to help individuals with dual eligibility. Most participants thought that the process would not go well—"a disaster," "a trainwreck waiting to happen"—because the six-week time frame was simply not sufficient. Of particular concern was the stipulation for random assignment to drug plans—the rules preclude states from selecting a plan for dual-eligible beneficiaries that matches their needs. "If I can't pick the plan, I don't want to do the auto-assignment," said one participant.

The issue paper and focus group reports are available on the Kaiser Commission Web site at www.kff.org/about/kcmu.cfm.

Dr. Gold is clinical associate professor of psychiatry at Georgetown University Medical Center in Washington, D.C., and chair of St. Elizabeths sesquicentennial educational symposium committee.