Tuesday, April 29, 2014

Prior Authorization - A Legal Document?

As part of the continuous harassment that is prior authorization, I recently received a form in the mail.  It was a repeat of one that I had already signed and faxed in. The only difference was this boilerplate attached to the bottom"

"I attest that the medication requested is medically necessary for this patient. I further attest that the information provided is accurate and true, and that documentation supporting this information is available for review if requested by the claims processor, the health plan sponsor, or, if applicable, a state or federal regulatory agency. I understand that any person who knowingly makes or causes to be made a false record or statement that is material to a claim ultimately paid by the United States government of any state government may be subject to civil penalties and treble damages under both the federal and state False Claims Acts. See, e.g., 31 U.S.C. §§ 3729-3733."

I suppose I should be grateful that the PBM in this case did not attach the 14 page federal statute. And that's right, this statute is a Civil War era statute that I am sure no legislator at the time or since then would have applied to the practice of medicine. What are the implications?

1. First is the clear alliance of PBMs with the federal government. There is no clear separation of where a private for profit business ends and the government begins. I have never sent out a form or a letter with a warning that governments at any level might enforce my recommendations or services. In fact, I have complained numerous times to government officials and agencies about managed care companies at several levels only to be politely told "We can't help you." Probably because they are tripping over one another to help out the managed care cartel.

2. Secondly (and this is a recurrent theme), we have the illusion that health care companies are policing doctors and holding them accountable. That's right - the same industry that is basically one of the largest taxes on most Americans and the same industry that has dismantled mental health care and transferred the mental health care of millions of Americans to correctional facilities. There is also an implicit threat very similar to the threat I wrote about during the billing and coding era.

3. The propaganda effect - practically all managed care intrusions into the practice of medicine are designed to shift financial and clinical risk to physicians. That would includes all of the other managed care schemes like report cards, capitation, pay-for-performance, utilization review, managed formularies and all other schemes to shift risk onto doctors. The net effect of this propaganda has been to adopt the propaganda as somehow being normative. The worst effect is that these insurance companies and MBAs push the propaganda as though it is scientific fact. It not only lacks scientific merit but they frequently do not know how to analyze the data. The best example I can think of is using the PHQ-9 to "measure" depression treatment in the state of Minnesota. This is not only an invalid application of the screening tool, but the state clearly does not have any way to analyze the longitudinal data in any scientific manner.

The blizzard of propaganda from the managed care industry has been a positive for them. It has such a deleterious effect on physician morale that nobody seems to be up for a fight. They have actually launched a new wave of propaganda that is very similar to the initial wave that was used to justify managed care in the first place. We are now seeing "collaborative care" studies that claim very positive results. Medicine and psychiatry in particular seem desperate in the face of managed care propaganda. One of the front page headlines in this month's Clinical Psychiatry News was:

Future of psychiatry may depend on integrated care.

I would submit that it does but not for the reasons claimed in the article. Integrated care will result in psychiatrists with considerable less knowledge than they currently have and they will be totally marginalized without a clear set of problems to treat. The only reason psychiatrists have not been put out of business so far is that we successfully treat a set of problems that nobody else does.

Standing around in a primary care clinic looking at PHQ-9 scores and monitoring the rapid and random prescription of antidepressants by nonpsychiatrists seems like a job for an MBA rather than an MD.

I am sure at the proper time, some business type will come to that conclusion and psychiatry in managed care systems will politely disappear.........

George Dawson, MD, DFAPA


  1. Amen.

    And, not just psychiatry. Most medicine Is in trouble. It will be "They pretend to treat us, and patients and doctors pretend we actually have a say in the matter."

  2. Recommendation: Call the insurance company and tell them that unless they desist from harrassing you in this way, you will resign from the panel. You also say you will explain what happened to their patients, recommend to these patients that they complain to their employers about the insurance company, and give the patients the name and phone number of the person at the company you are dealing with. Let them deal with the patient.

    Doctors don't know that, if they do this, insurance companies will usually back down or come up with something agreeable to save face. If not, follow through with what you said. Hostile and/or entitled patients can be useful resources.

  3. "Standing around in a primary care clinic looking at PHQ-9 scores and monitoring the rapid and random prescription of antidepressants by nonpsychiatrists seems like a job for an MBA rather than an MD."

    Or an MD in Bangalore working for 10 percent of your customary salary. I think that many of these APA psychiatrists rushing to support this should have talked to a few diagnostic radiologists first. If that happens, will the APA apologize and reimburse us for their mistake?

    I don't think its naivete as much as they don't have skin in the game. Asking tenured academics to represent the interest of private practitioners is a fool's game. Why should they care?