Conflict of interest and psychiatry - what's missing?

A new article looking at conflict of interest in psychiatry was presented on another blog to suggest that new rules are required to improve transparency. The article takes a look at six cases and the process used by Sen. Charles Grassley to publicize these cases. The article suggests that the reason for publicizing these cases was in order to support Grassley legislation (Physician Payment Sunshine Provision).  According to the article it was attached to the Patient Protection and Affordable Care Act and was never voted on alone. 

These cases were repeatedly publicized in the popular media and some of the problems with these cases and Grassley's analysis were never adequately discussed.  The clearest example is the case of Alan F. Schatzberg, MD of Stanford University. He was the chairman of the Department of psychiatry and when Grassley investigated the matter at the level of Stanford University and several pharmaceutical companies. You can read the exact details in this paper but the bottom line is that Stanford University has always maintained that it handled potential conflicts of interest in an appropriate manner consistent with their policies. They actually published a statement on their web page at the time.  He remained the department head and although he was apparently temporarily removed as the principal investigator on a federal grant but he was later reinstated. The authors of the article in this case suggest that exposing the conflict of interest had negligible effect on the outcomes in this case, but the fact is the case was handled according to university policy.

There are really two key elements in this paper that are critical. The first is why Grassley went after psychiatry in the first place. The article suggests this occurs because his aide Paul Thacker "Combed  the media for stories of influential physicians with industry ties. He then requested the physicians conflict of interest disclosures from their AMCs and compared them to payment schedules obtained from companies."  I had always wondered why physicians from other specialties were never mentioned or consultants from other departments. It is fairly well known that scientists and engineers can make substantial incomes to supplement their university salaries based on their expertise. So why was the "media combing" restricted to psychiatry?

If I had to speculate, I would suggest that media bias against psychiatry is a well known fact. It has actually been investigated and the frequency of negative press that psychiatry receives relative to other specialties is well known. (see paragraph 4)  The popular press has an automatic media bias against psychiatry and it should come as no surprise that prominent psychiatrists are investigated and reported more frequently than other specialists. This is why “combing the media” is really not a legitimate research method. It should be fairly obvious that prominent university affiliated physicians of all specialties have similar conflicts of interest and that the business stake in other specialties is probably significantly higher.

The second element that should be obvious to anyone skeptical of Congress is Grassley's quote in the article "The whole field of medicine is connected by a tangled web of drug company money. For the sake of transparency and accountability should the American public know who their doctor is taking money from?"  That sounds like there is an obvious answer in there somewhere but the U.S. Congress is the best case in point that transparency is essentially meaningless. There is probably no better example than Sen. Grassley himself.  You don't have to look too far to find campaign donations that align with the votes and the Senator's denial (see paragraph 8) that there is any connection.

These simple facts are left out of the Journal article and that represents a serious flaw to me. Is the U.S. Congress is a shining example of disclosure becoming a license to do whatever you want to do? If that is the case you really don't have the basis to suggest that transparency will allow the "power of sunlight to disinfect". It clearly does not have that effect in Congress.  That is at the minimum an appearance of a conflict of interest on par with any scenario described in this article.  When I point this out - the usual rebuttal is that doctors should have a higher standard when it comes to the appearance of conflict of interest.  Is that really true?  Should a doctor who already has a fiduciary responsibility to a patient and the patient's well being have a higher conflict of interest standard than one of the 100 most important law makers in the country?

The other issue here of course is that psychiatrists are conveniently thrown under the bus. Despite the qualifier in this paper is that "Nor did Grassley ever assert that psychiatry was more problematic than other specialties." (p 5).  You really don't have to make an assertion when psychiatry is apparently the only field you are investigating. That bias is totally consistent with one of the themes of this blog. 

When all else fails you can more easily scapegoat psychiatrists.  So why look for anybody else?

George Dawson, MD. DFAPA

Chimonas S, Stahl F, Rothman DJ. Exposing conflict of interest in psychiatry:
Does transparency matter? Int J Law Psychiatry.
2012 Oct 1. pii: S0160-2527(12)00072-6. doi: 10.1016/j.ijlp.2012.09.009.

[Epub ahead of print] PubMed PMID: 23036364.

Happy Labor Day - To All the Docs On The Assembly Line

When I first started working in medicine I was the Medical Director of an outpatient mental health clinic.  We had a staff of 8 psychotherapists, 2 nurses, and 2 case managers.  There were three transcriptionists to type up all of our notes.  Every person I saw had a typed note to document the encounter and all of the charts were paper.  There was no electronic health record.  If a person needed a prescription, I would write one or call the pharmacy and that was the end of it.  The majority of my time was spent speaking directly with patients and I could generally do all of the dictations in about 2 hours per day.

After three years I moved to a hospital setting.  There were three inpatient units with 6 psychiatrists and two transcriptionists.  One of the transcriptionists specialized in paperwork specific to probate court proceedings.  There was an additional pool of transcriptionists available 24/7 on any phone in the hospital for immediate documentation of any clinical encounter.  The admission notes were typed on two or three sheets and inserted in the chart.  Daily progress notes were typed on adhesive paper and pasted into the chart.  After I signed the note, a billing and coding expert came through and submitted a billing fee for the work that had been done.  The same process was in place with pharmacies.  Call them or send them a written prescription and it was taken care of.   Every Sunday I would go to the basement of the hospital in the medical records department and sign all of the areas I had missed to complete the charts.  It was the early 1990s and the administrative burden was certainly there but it was a manageable ritual.

Over the next decade things got much, much worse.  Even in the blur of a retroscope it is hard to say what happened first.  I would guess it was the political theory that health care fraud was the main driver of health care costs and the misguided effort by the federal government to crack down on doctors.  That led to the elimination of the billing and coding experts.  Doctors now had to waste their time in seminars devoted to making them experts in what is an entirely subjective process.  No two coders agree on the correct bill to submit.  How can you teach that lack of objectivity to doctors?  The end result is that the billing and coding people were eliminated or reassigned and doctors took on another job unrelated to medicine.

The next phase was the electronic health record (EHR).  It required that doctors learn the interface (more seminars and training).  Once that was accomplished it was decided that they could also learn to enter their own notes - either really clunky ones using EHR derived phrases or more natural ones with a fairly frequent embarrassing typo using voice recognition programs.  That eliminated the transcriptionists and required much more training. During the transition period I still went in to medical records every Sunday.  I expected to see a staff person there who I had seen every Sunday for 15 years but one Sunday she was gone - a casualty of the EHR.  The end result was doctors with a couple of new jobs and the elimination of both transcriptionists and medical records people.

At about the same time, managed care companies started to ratchet up the pain.  In an inpatient setting you could get one or two "denials" per day.  A denial is the managed care company saying that they refuse to cover the cost of care because the admission was not "medically necessary".  That is managed care rhetoric for "we have decided not to pay you."  These denials are purely arbitrary and have nothing to do with whether a person needs care or not.  The best examples at the time were people with alcoholism or addiction who were suicidal and needed to be detoxed and reassessed.  The standard managed care denial at the time was "This patient should be treated in a detox facility."  The obvious problem was that not every county has a detox facility and those that do will not accept people making suicidal statements.   So the next new job became battling with these companies who were essentially getting free care for their health plan subscribers if you did not jump through all of the hoops necessary to appeal.

Slightly later, managed care decided they could apply the same denial strategy to pharmaceuticals on the basis that cheaper drugs are as good and all drugs in the same class are equivalent.  It turns out that nether of those assumptions is accurate, but in America today business and politics always trumps medical decision making.  This prior authorization process created a blizzard of paperwork that ties up a lot of clinic time.  One study estimated 20 hours per week (across all employees) per physician  on average.  That means if your clinic has 5 doctors in it - 100 hours per week of the total hours worked is used strictly to deal with insurance companies.  It also adds another job to what the doctor already does.

So in the time I have been practicing medicine let's add the number of jobs that have been accreted into the administrative side of medicine for all physicians.  Billing and coding expert + transcriptionist + EHR interface user + voice recognition user + utilization review responder + prior authorization responder totals 6 new jobs in the past two decades, none of which came up in medical school.

With all of that "efficiency" we should expect health care costs to plummet or at least stay the same.  As we all know that has not happened.  The politics and business interests driving this are in the business of making money.  Physician and hospital reimbursement is essentially flat.  One of the easiest ways to make a buck is to have the physicians doing way more administrative tasks and fire the employees that used to do them.  You can also make money by putting up the usual obstacles to doctors doing their jobs of treating patients in hospitals or clinics until they just give up.  I have been so burned out at times that I put a cursory note in the chart to say exactly what I did.  That note did not meet coding requirements so I did not submit a bill.  At some point you just have to stop working.  I know that I am not alone in getting to that point.

So congratulations to all of the docs who are now laboring on this vast assembly line that we now call American medicine.  It is the ultimate product of what Congress, the White House and big business can do.  We can only expect continued "improvements" or "efficiencies" under the new health care law.  It is an assembly line that discourages quality or innovation and that also makes it unique.

Happy Labor Day!

George Dawson, MD, DFAPA

Health Care Complexity, Politicians, and Judges

There is so much wrong with the Affordable Care Act it is difficult to know where to start. According to a recent article in JAMA, I learned that Accountable Care Organizations (ACOs) are charged with improving the quality of care for Medicare patients at less cost. Any psychiatrist in the country who has witnessed the decimation of mental health care justified by that same rhetoric should be skeptical. 

So far the government has been again engaged in a highly coordinated effort to get the ACO initiative up and running. On October 20, 2011 the final rules for ACOs were released and on that same day the Federal Trade Commission and Department of Justice provided guidelines to address the antitrust issues of ACOs.  The JAMA article discusses five major issues related to the creation of ACO's many of which are unrealistic. As an example the antitrust guidelines suggest that ACOs that have a less than 30% market share are "highly unlikely to raise antitrust concerns".  In that landscape, the government expects that ACO's will develop and use quality measures, avoid exclusive relationships with hospitals and specialists, avoid cost shifting via the leverage of large physician groups to private payers, and be monitored to avoid gaming the risk-adjustment scheme. All of these dimensions are highly problematic.

The most problematic aspect of the Affordable Care Act is the same problem that every major piece of legislation in the United States has and that is that nobody reads it. I have seen quotes on how large the actual bill is ranging from 1000 pages to 2700 pages.  I first became aware of the fact that hardly anyone in Congress reads large bills in 2003. At that time I was following the progress of HR 1 (The Medicare Prescription Drug Bill).  I was watching C-SPAN and Sen. Harkin commented that the 1000 page bill was delivered to members of Congress on Thursday morning so that they could debate it on the weekend and vote on Monday morning. He was the first of many senators to acknowledge the fact that nobody would ever read the bill.

At the time I thought that disclosure was astounding. Here we have members of Congress whose full-time job is to design legislation and they are not actually reading and debating a bill that regulates a huge part of the economy and most people's healthcare. I won't even go into the fact that the pharmaceutical lobby was so satisfied with the final result that most of them left town on Friday.

The Affordable Care Act provides us with a new insight into how our government operates. In this case the constitutionality of the bill is also being debated and that was presented to the Supreme Court about two weeks ago. In the Wall Street Journal article it is official that Supreme Court justices are no more likely to read the bill than members of Congress. Justice Scalia is quoted: "You really want us to go through these 2,700 pages? And do you really expect the court to do that? Or do you expect us to give this function to our law clerks?"  We have a check and balance system set up where the check and balance is as defective as the original process.

The overall process here illustrates why it was doomed from the start. The Affordable Care Act is a highly experimental piece of legislation at best. In order for it to function as advertised many unlikely events will need to occur. That would seem obvious to any intelligent person reading the bill but as we have determined there are no members of Congress and no justices in the Supreme Court that will actually do that.

George Dawson, MD, DFAPA

Wall Street Journal. "Complexity is Bad for Your Health" April 8, 2012.

Dawson G.  Medicare Drug Bill #1,  #2,  #3  Three real time posts on my observations on the Medicare Prescription Drug Bill in 2003.

Schleffer RM, Shortell SM, Wilensky GR.  Accountable Care Organizations and Antitrust: Restructuring the Health Care Market.  JAMA. 2012;307(14):1493-1494.