Warren v. Dinter - More Implications Than Malpractice Law

I have few comments about this case that is written about from the perspective of malpractice law and the implications for informal consultation.  In this case, Richard Dinter, MD was a hospitalist employed by one of the main hospital systems in Minnesota.  By way of background, over the past 20 years most hospitals in the United States are now staffed by hospitalists who are generally internal medicine or family medicine trained specialists dedicated to admitting people to hospitals, treating them while they are there, and discharging them. In the overall history of medicine this is a fairly recent movement.  Before hospitalists, this function in most hospitals were covered by rotating assignments of staff from these departments or in the case of some private practices - the practitioners would see anyone from their practice admitted in the AM and see their clinic patients in the afternoon.  The hospitalist movement seems to have developed to create more efficiency in the system but an undoubted byproduct has been less personal care by physicians who don't know the patient as well, more control over physician practice by business entities, and an increase in the amount of care delivered by proxies or physician extenders.

In this case Susan Warren presented to a clinic in Hibbing Minnesota with abdominal pain, fevers, and chills. She had an elevated white blood cell count. The nurse practitioner seeing her called the hospital system where the call was randomly assigned to Dr. Dinter. The question was whether or not the patient should be hospitalized.  Hospitalization was not recommended and the nurse practitioner did not seek the hospitalization on her own. The patient was discharged home and died of sepsis. The family sued both the physician and nurse practitioner.  In Minnesota nurse practitioners can practice independently without physician supervision.  Reversing prior precedents, the Minnesota Supreme Court ruled that a physician-patient relationship was not necessary for a medical malpractice claim. Instead they established a new standard of reasonable foreseeable action. In other words, a malpractice claim could be initiated if harm suffered was a “reasonably foreseeable action” of a physician’s actions.

Amici curiae briefs were filed by the Minnesota Medical Association partnering with the American Medical Association and separately by the Minnesota Hospital Association. The main arguments were that this standard would stifle collaboration and informal consultation and that might possibly lead to patient harm. The most shocking result of this court decision is that a physician can be sued without any formal physician-patient relationship.  On the surface it all seems to be a standard malpractice issue complicated to some degree by new treatment relationships. But are there larger issues here. The fact that the Minnesota Hospital Association filed an amicus brief suggests that there are.

Minnesota has had the highest penetration of managed care organizations of any state for a long time. Practically all of the care the state is managed by three major healthcare companies who dominate the market. They have their own standards organization that sets guidelines and standards for certain practices in the state. A good example would be the Diamond Project that led to the state government adopting a standard that they would collect depression rating scale scores as a proxy for the quality of depression care being delivered in primary care settings in the state.  This was an early form of “collaborative care” that is currently being pushed by several organizations. In collaborative care for psychiatric purposes, a psychiatrist reviews charts, rating scales, case manager notes, and possibly primary care physician notes and makes a recommendation for a specific treatment. The original Diamond Project focused only on depression and antidepressant prescriptions. I attended the APA sponsored course on collaborative care and learned that according to some standards all psychiatric disorders can now be treated remotely without seeing the patient.

Managed-care organizations and every healthcare plan has a vested interest in providing this type of care to their patient-subscribers. For the past 20 years they have been putting “physician extenders” in hospital and clinic settings with varying degrees of supervision. Many of these personnel like nurse practitioners can now practice independently without physician supervision. The only way physician supervision occurs in many cases is because of local rules within the health plan that employs the physician and the physician extender.

I have seen tremendous variation in how physicians work with nurse practitioners and physician assistants. In one case, I saw a physician working with four nurse practitioners in an outpatient clinic and in half a day - they would see 40 to 60 patients. The incentive for that arrangement was the physician would get the “productivity” numbers.  The organizations call this “population-based medicine” for the emphasis on treating large numbers of people rather than individual patients.  Of course for physicians, there is really no such thing. Seeing large numbers of patients, even with nurses, nurse practitioners, or physician assistants - should not reduce the amount of information needed in the time needed to make decisions and recommendations in that person’s best interest on that day. Some organizations have triage systems in place even before patients see anyone. I wrote about one of those systems four years ago that led to the inappropriate care of an 80-year-old man after a fall.

This court decision is really a managed-care friendly decision in that it affirms a system where physicians have no direct contact with patients but are responsible for the outcomes. Like managed care health systems, the court is basically saying that physicians can direct healthcare provided by nonphysicians remotely. The implication here is that the quality will be the same. A further implication is that the healthcare company does not end up appearing to be a two-tier system, staffed at one level by physicians and at another level by nonphysicians. That would not allow for the indiscriminate draping of quality banners over all the buildings in a certain organization.

Some people see this court decision as a “guild issue” or scope of practice issue.  I have already seen arguments about physician extenders replacing physicians and healthcare organizations and the implications of those maneuvers. Since nurse practitioners can practice independently - this is about physician supervision or collaboration available in health care settings that assume physicians can operate that way.

From a strategic standpoint, this decision points out that you may not be able to ration physician expertise on the one hand and avoid negative clinical or legal outcomes on the other. The average patient does not appreciate this effort until they realize that significant medical care has been denied and the physicians treating them are powerless to advocate for them. Although this case has not been litigated in a civil hearing - the ground rules have been suggested. In this case we have a nurse practitioner who according to Minnesota state law is licensed to practice independently without physician supervision. That nurse practitioner contacts a physician to discuss the case and the physician is implicated in the outcome. Managed-care organizations have successfully used this dynamic for years. The clearest example is the imposition of case managers in hospital settings telling physicians when they must discharge patients based on business rules rather than medical indications.  Another common example is the “physician reviewer” who reviews medical care remotely without any direct knowledge of the patient and makes a decision on whether they should be discharged from the hospital or not. In that situation physician reviewers are immune from liability according to federal law. Warren v. Dinter shows that there may be no such exemption for physicians working in healthcare organizations who provide consultation about medical care and hospital utilization.

Once physicians were sufficiently undermined so that their opinion carried no more weight than nonmedical business personnel, healthcare businesses were able to dictate medical care they way they wanted to. That direction is generally to make a profit and in the case of publicly held companies - to make as large profit as possible to satisfy their shareholders.  

This decision suggests that there may be no protection from civil litigation similar to the federal immunity for business physician reviewers for any working physician making recommendations on the basis of the same limited data.

George Dawson, MD, DFAPA 

Less Is Less - A World of Difference Between Psychiatry and Cardiology

I read Lisa Rosenbaum's opinion piece in this week's New England Journal of Medicine (1). She discusses both sides of the rationing coin. On the one hand, we don't want to reduce resources to the point that people do not get necessary care. On the other hand there are forces including financial incentives and the inability of physicians to tolerate the diagnostic uncertainty of not performing the necessary tests that lead to both increased cost and in some cases unnecessary risk to the patient. She provides an example from her personal medical history on forgoing a recommended test with no associated adverse outcome. A lot of the article is written from her perspective as a cardiologist or cardiology fellow. I can recall, the think tank studies from the 1980s suggesting that coronary artery bypass surgery was overutilized. There are many studies that suggest that medical treatment of coronary artery disease provides similar outcomes. Today we hear the same arguments about the treatment of the atrial fibrillation epidemic and the equivalence of rate control versus rhythm control. The options are presented as a coin toss to many patients. But in both cases it is much more than that. Anytime population based averages of care are applied across large populations there will be a significant number of people who do worse than the norm and may have done better with the other option. My concern has always been, the implicit pressure by healthcare companies to make money by exerting pressure in the direction of the least expensive option right up to including no care at all.

Dr. Rosenbaum discusses the "less is more" movement and the Choosing Wisely campaigns to reduce unnecessary care. She discusses the early role of the Dartmouth Atlas in pointing out the lack of correlation between cost of care and outcomes - a notion that has been discredited (2) but it was the mantra of administrators for nearly two decades.  She concludes that these movements resulted in the idea that "less care is better care or that more care is harmful."  She reviews more recent data that higher spending is associated with better outcomes. She includes recent research on unnecessary admissions and how Medicare beneficiaries discharge from the emergency departments (ED) of hospitals with the lowest admission rates were 3.4 times as likely to die with a week than similar patients admitted to hospitals with higher admission rates - even though those same patients were healthier.

She discusses overdiagnosis in cardiology. Unlike psychiatry, cardiology has a considerable array of biochemical markers, electrophysiological studies, and imaging studies that are very useful in the diagnosis and management of their patients. She illustrates the trade offs involved in considering false positives for troponin and how liberalization of the cut-off values leads to better diagnosis and treatment rather than overdiagnosis. In the area where I currently practice, the entire landscape for diagnosing and treating suspected acute coronary syndrome (ACS) has changed significantly. Nobody tries to guess if chest pain has a cardiac origin or not.  Middle-aged patients are generally admitted and tested with troponin levels and an exercise stress test the following morning if the troponins are negative. If the stress test is negative they are sent home. In most acute care metropolitan hospitals there is ample intensive care and telemetry space to accommodate all of these admissions. The cost of that overnight admission to cardiology exceeds the cost of a week long admission to an inpatient psychiatric unit with a psychosis diagnosis.

What is the parallel process on psychiatry? A patient in crisis presenting to an ED of a metro hospital in crisis has no similar guarantee of cautious screening. In the majority of cases they will never see a psychiatrist. In most cases the assessment and screening is done by nonphysicians. In addition, diagnoses and syndromes are generally secondary in the discharge process. The only way that patient gets admitted is dangerousness to self or others. That could be due to an acute intoxication, an emotional overreaction, a mood disorder, a developmental disorder, a neurodegenerative disorder, or a psychosis. The only thing that counts is the dangerousness. There are no biochemical markers or imaging markers of dangerousness. There is significant disagreement in many cases among clinicians, patients, and their families. If a person is admitted either voluntarily or on a legal hold - in any case they will typically find themselves sitting on a psychiatric unit until somebody determines that they are no longer dangerous. Hopefully they will see a psychiatrist and other skilled professionals like trained psychiatric nurses, social workers, and occupational therapists - but there is no guarantee. The issue in an acute dangerousness based psychiatric hospitalization is not a question of overdiagnosis - but whether the patient will get the correct diagnosis and an adequate medical evaluation and discharge plan.  The driving force for that is rationing. The cost of an overnight stay on a cardiology unit with telemetry, blood tests, and an exercise stress test in the morning easily exceeds the payment for complex psychiatric care. I would say that complex psychiatric care is the equivalent to treating a person with a psychosis, extreme mania, or life threatening catatonia or depression. In general we are not worried about the issue of overdiagnosis. People flee psychiatric units if they are given the opportunity and they don't really care if they get diagnosed or not. Psychiatrists cannot present them with an array of options because there aren't any.

When I saw the term overmedicalizing in Dr. Rosenbaum's title - I wondered if she was aware of its Szaszian origins? Szasz was apparently so enthralled by a form of psychiatric treatment that was totally subjective and more akin to a literary critique that he suggested society has an interest in using psychiatry as a way to exert social control over certain subgroups.   The logical conclusion is that mental illness is not a disease and calling something an illness is strictly a power play.  For some reason society and its unholy alliance with psychiatrists is seeking to exert power over a subset of society for unclear reasons. I doubt that Dr. Rosenbaum is using the Szaszian definition. She is probably referring to any number of situations where non-disease is treated as disease.

There are many problems with Szasz - not the least of which is how he would end up treating any number of severe mental conditions. More modern authors on what is and is not a disease seem confused about the imprecise definition, especially in the absence of gross pathology. There is no family member affected by schizophrenia, bipolar disorder, depression, alcoholism, or addiction that doubts for a moment that these are diseases. They generally don't doubt that psychiatrists, at least until very recently were the physicians most interested in treating these problems.

Dr. Rosenbaum's theme does not seem to apply to psychiatric practice. There are no expensive tests to overutilize. Stays on inpatient units are capped by ridiculously short lengths of stay that do not reflect the severity of illness.  Even then - admissions to psychiatric units are generally under the control of emergency physicians.  This is part of the oversimplication, that she referred to. That oversimplification characterized all inpatient stays by diagnosis related groups (DRGs) and suggested that all inpatient stays could be kept to a certain number of days or cost. Nothing else was necessary. This led to three outcomes that led to very subpar care. The first outcome was the deterioration of inpatient services. Rationing does not maximize state of the art care and practically all inpatient units are essentially observation services waiting for people to become less dangerous. Dialogue with patients on acute care units is essentially focused on that issue. Addressing the psychiatric disorder is a consideration only as it applies to dangerousness.  I have had many utilization reviewers tell me that they would no longer pay for the treatment of extremely ill people because they did not seem to be dangerous. 

The second outcome was splitting off addiction treatment. At some point, a large number of detox admissions were directed to psychiatry because medicine units no longer did detoxiification. Then at some point to capitalize on the DRG payments, psychiatric units not longer did detox. patients with addiction were sent from the ED to a county detox unit. The only time they came back is if they experienced seizures or delirium tremens.  The overall rationale is saving the insurance companies money.  They don't cover people at county detox units.

 The third outcome is that patients with severe psychiatric disorders are sent to jail rather than inpatient units. This has resulted in county jails becoming the largest psychiatric hospitals in the United States at a time when psychiatric beds per capita here are among the lowest in the world according to OECD data. All of these changes are associated with a tremendous lack of quality and would be a national embarrassment - if they were not viewed as cost effective by the businesses and governments in charge. The American Psychiatric Association and other district branches still incorporate the cost effective rhetoric when in fact, psychiatry left cost effective in the rear view mirror thirty years ago.

Psychiatrists don't have expensive procedures to order.  In psychiatry less is less (or no) time seeing a psychiatrist.  Less is no time being treated in a medically supervised and therapeutic inpatient or detox unit when you need it.  Less is no psychotherapy that might work for you.  Less is no case management services.  Less is no public health nursing.  Less is not taking the best medication because a pharmaceutical benefit manager says you will have to pay full price for it.  Less in no available child psychiatrist when they are needed.  Less is not getting your blood pressure checked in a public clinic because there are no blood pressure cuffs.

Less in psychiatry is obviously far less than any other speciality.

That brings me to the last concept in the article illusions of value. There is no greater illusion of value than current psychiatric care and that is not because of psychiatrists. To give a clear example, I am an excellent diagnostician - both medical and psychiatric illnesses. I can figure out what is wrong with people and come up with a plan to address all of those issues. I can't do it in a 15 minute appointment. I can't do it if I have to type up all of my encounters like a stenographer or waste my time supporting horrible electronic health record software. In the case of people with severe problems, I can't do it without staff people who can get the patient to the appointment to see me and make sure that the person follows up with all of my recommendations. Without all of that infrastructure on the outpatient side, I will end up seeing about 60% of the people who are scheduled and the average person coming back will tell me they are taking their prescribed medication half of the time. Almost all of that supporting infrastructure has been eliminated in the past 30 years and managed care organizations have set up psychiatric services based on the prescription of a medication. Even if you have a severe problem. Show up 3 or 4 times a year, have the psychiatrist ask you a few questions, and get enough refills until the next appointment.

Psychiatry is actually a paradigm that the rest of medicine should look to in terms of less is less. In her final sentence Rosenbaum describes "less is more" as an aphorism that is "better suited to telling coherent stories than to the complex decisions faced by doctors and patients." I could not agree more. My only qualifier would be that the administrators are always telling their coherent stories that make it seem like they know more than physicians know about medical practice. They do a great job of selling it and convincing people that a symptom checklist and an antidepressant prescription constitutes optimal care. 

That is the only way that the current abysmal psychiatric services offered by large health care corporations could get a pass.



George Dawson, MD, DFAPA







References:


1: Rosenbaum L. The Less-Is-More Crusade - Are We Overmedicalizing or Oversimplifying? N Engl J Med. 2017 Dec 14;377(24):2392-2397. doi: 10.1056/NEJMms1713248. PubMed PMID: 29236644.

2:  Sullivan K.  The rise and decline of the Dartmouth Atlas.  The Health Care Blog, September 25, 2016  http://thehealthcareblog.com/blog/2016/09/25/the-rise-and-decline-of-the-dartmouth-atlas/

Another Bad Editorial Decision and more.....

I am on record recently pointing out how top medical journals have evolved to the point that they are posting a continuous stream of opinion pieces of variable quality.  It is not uncommon to find that from week to week diametrically opposed views on topics are published.  The most alarming trend in the posting of business views; usually along the lines that there needs to be continuous business reform in health care.  These are basically opinion pieces looking for a political foothold.  The precedent of course is managed care.  After it gained a political foot hold in the Clinton administration it became a business worth hundreds of billions of dollars.

In the case of managed care it was sold as widespread "reform".  After 30 years of managed care rationing the per capita health care costs in the USA are quite unbelievable when compared with even the next most expensive system ($9,086 in USA versus $6,325 in Switzerland).  The other top ten nations are seriously outdistanced.  Rather than acknowledge managed care as just another political flop there are endless editorials on how it really slows the growth of health care.  There are editorials of how it is really a success despite these outrageous numbers and nearly complete hegemony by managed care and insurance companies.  It is difficult to see how responsible editors of medical journals can continue to publish this pro-business propaganda.  They are certainly more circumspect about making these pages a sounding board for the pharmaceutical industry.

The largest divergence when it comes to health care costs is a managed care propensity for a disproportionate focus on mental health and psychiatric services.  This is nothing new.  It has been well documented since the  Hay Group found that from 1988 to 1997 that a total value of health care benefits for over 1,000 large U.S. employers declined by 10%.  Of the decline general health care benefits declined by 7%, but behavioral health benefits declined by 54%.  Behavioral health is managed care speak for mental health and psychiatric services.  Those same services dropped from 6% to 3% as a total percentage of health care costs.  While general medical services increased by 27% outpatient mental health services dropped by 25%.  Mental health benefits from employer based health insurance dropped by 50% between 1988 and 1998.  The true costs of managed care rationing have never been seriously examined.  There is an obvious conflict of interest when the government basically invents and industry based on a flawed political theory and the system floats based on these invented special interests.  

I did not really think that these opinion pages could be any worse until I happened to open up JAMA Psychiatry the other to do some reading while I ate my Wheaties.  I ran across an article called "What to do when your managed care firm says no."

The answer from my experience is nothing - you are basically out of luck.  In my experience managed care companies don't care if you live or die.  They don't care if you have the world's worst eating disorder.  They don't care if you have tried to kill yourself while intoxicated and your psychiatrist is saying that you will absolutely use alcohol, heroin, methamphetamine, dextromethorphan or any number of drugs immediately if you are not sent to treatment after acute stabilization.  They don't care if you need a longer period of time in the hospital.  They don't care if you have been committed for a suicide or homicide attempt.  I am not saying all of this just because it is true.  I am saying it to point out something that is often overlooked.  Why would a managed care company or MCO care?  They have never met you and have no personal responsibility to you.  As a business, especially in the new era of business management - they basically have a responsibility to make money for their shareholders.  The caring aspect of MCOs is really a public relations stunt.  They involve your doctor and make it seem like their decision - is your doctor's decision.   They waste your doctors time in order to make it seem like their refusal to pay for your care is somehow a conjoint decision with your doctor.

But back to the article.  Here we have a managed care insider giving advice to patients and physicians on how to deal with their denials.  I would consider this all tongue in cheek advice if it was not sitting right there in JAMA Psychiatry.  I will focus on a most familiar scenario denial of inpatient care.  This is a case of a hospitalization for schizophrenia where "the hospital tells the mother that it is time to discharge her son because the MBHO (Managed Behavioral Health Organization) says so and has an appointment for her son to be seen a month after discharge" (p. 1109).  The author suggests that in the case of this dispute the vendor will have a formal appeals process and that will include "a review by a psychiatrist not on the MBHO's payroll."  That has not been my experience.  The review is generally done by psychiatrists a long distance away.  They may not be licensed in the state where the patient is hospitalized.  The ones I have talked with are either openly hostile, pretending to be on your side, or clueless about the severity of inpatient problems.  Keep in mind that most psychiatrists do not practice in inpatient settings beyond their training years.  I have never seen a study that looked at whether these reviewers were actually treating very ill psychiatric inpatients - but from my conversations I think they were not.

The author goes on to say that the family can then apply to the employers benefits manager to apply leverage to the MBHO and have leverage in the case of inadequate care.  What is wrong with that picture?  For starters any sequence of events where clinical decisions are being made by business types is by definition - inadequate care.  Secondly, there is an inherent conflict of interest when your employer and an insurance company they are contracting with start negotiating your medical or psychiatric care.  Once again - neither of them has a responsibility to you for giving you the best possible medical advice.  They are giving you a business decision that saves them both money and calling it a medical decision.  The MBHO is protected against liability from that decision by federal law.  Your employer is protected by saying it was the decision of the MBHO and not them.  If you really think that your employer is interested in your personal health, go talk to the decision maker in person and note their level of interest.

The final vignette provided by the author is there to justify managed care.  It has been their war cry since day one and that is excessive utilization.  In this case we are lucky to have Big Brother watching in the case of psychotherapy delivered so inexpertly that the therapist states: "I am this patient's only friend so she needs to to keep seeing me."  This was after years of treatment.  I think that we can  all breathe a sigh of relief that an MBHO being paid millions plus incentives to ration psychiatric care can identify the worst therapist in the USA after years of therapy.  It is a miracle of modern management.

When you have editors who accept this level of an article it is a direct insult to anyone who has personally dealt with these companies and who knows what is going on.  It is a direct insult to the medical profession and physicians who have dedicated their lives to learning complex, highly technical profession to suggest that they should be clerical workers and work for free as employees of managed care companies.  It is an insult to desperate patients and their families who put up with all of paperwork, inefficient billing and arbitrary denials of care.

If the editors of medical journals are not bright enough to question the accuracy of a piece like this or they have not had the clinical experience of dealing with the constant harassment of managed care companies - they should defer the commentary section to somebody who knows what they are talking about.

Better yet - time for a moratorium on business and political commentary in medical journals.  When you try to complete with blogs - keep in mind that you are competing with a low standard.  That turns out to be no competition at all.  


George Dawson, MD, DFAPA

Reference:

1: Essock SM. What to Do When the Managed Care Firm Says No.  JAMA Psychiatry. 2016 Sep 28. doi: 10.1001/jamapsychiatry.2016.2409. [Epub ahead of print] PubMed PMID: 27680607.

Supplemental -  The 4 x 6 Card on Real Health Care Reform

No room for this in the original above.  The solutions to businesses and business managers making medical decisions about your health care is like most political quagmires in this country - very simple.  You can fit it on a 4 x 6 inch index card.

It goes like this:

1:   All managed care (MCO, MBHO) decisions are between the patient and the company.  The doctor is out of the loop.  The doctor advises the patient, the company says yes or no on the payment.  The doctor may have an alternative or the doctor may not.

2:  The doctor does no appeals , paperwork, reviews with the MCO.  Why would he/her?  The doctor does not work for the MCO and does not get paid for all of the time it takes to engage in what are business processes.  The doctor should not care what anything costs the MCO.  They have a tower of MBAs with nothing else to do but figure that out.

3:  The same process is true for PBMs (pharmacy benefit manager) - the pharmacy equivalent of MCOs.  The doctor does not work for the PBM and does not get paid for all of the extra time each day to essentially justify their decisions.  PBMs have another tower of MBAs with nothing else to do but price drugs to their advantage. 

4:  The MCO is liable for damages related to any of their financing decisions that result in harm to the patient.  No federal exceptions.

5:  Each state has an independent arbitration board comprised of physicians who are actively practicing in the discipline where the decision is being appealed.  The physicians are all actively screened for conflict of interest like the Medicare Peer Review Organizations that found there was no excessive use of mental health services or anything else in about 1998.  The arbitration board should contain only physicians - no insurance company insiders dedicated to shield the managed care industry.  Direct appeals by the public should be encouraged with the same amount of vigor that the public is actively solicited to complain against their physicians.   

Steps 1-5 above would assure physician recommendations in the best interest of you the patient rather than the financial interest of the managed care organization.  Unfortunately with Managed Care 3.0,  the rationing in many cases has been internalized.  Today physicians can be in a clinic or hospital setting that has internal case managers telling them what to do.  When managed care companies rationed some places out of business they were very successful in acquiring medical groups and facilities.  In other words; the doctors, the hospitals, the clinics and the pharmacies are all owned and run by the managed care company or a shell company.  They all get their marching orders from people in the management class pretending to be medical experts.

That should be a major problem - but in the manner of Orwell - if you use the term health care reform a thousand times - most people believe it happened.

Just When You Thought American Healthcare Could Not Get Any Worse.....

I was on a vacation/family reunion last weekend about 150 miles north of the Twin Cities and 120 miles west of the only large northern metro area.  We were in the heart of lake country and about an hour from the closest emergency department (ED).  About 20 people of all ages there  for a few days to get reacquainted after a number of years, enjoy some good traditional foods, and outdoor activities.  Things were going very well until the last day.  Everyone was exiting the lake home to go to a local pizza establishment.  One of the family members missed the last step and fell hard to the pavement, knocking the lens out of his eyeglasses and sustaining a contusion/abrasion over the left supraorbital ridge.   No loss of consciousness.  He did sustain an abrasion on the left hand with some residual wrist pain.  He has some chronic medical problems but is not on anticoagulants.  Another family member is a nurse and applied an ice bag and cleaned a small laceration in the area of the abrasion.  It did not appear to need sutures and it was steri-stripped.

The only other bit of information that is necessary about the injured man is that he is 80 years old.  As a geriatric psychiatrist I ran down the usual considerations of the old approaching the old old - especially anatomic traction on bridging veins and subdurals from that injury.  I did not want to miss any needed brain imaging protocol based on these factors.  I decided to call the local hospital emergency department and run it by the triage nurse.  The call went like this (this is not a transcript).

Hospital:  "Can I help you?"
Me: "Yes - I am currently out at a lake cabin and a family member took a fall and struck his frontal area.  No loss of consciousnesses, headache, visual change, or neurological findings.  I would like to talk to your ED triage person to see whether imaging is indicated."
Hospital:  "Is he from Minnesota?"
Me:  "No he is not."
Hospital:  "We cannot allow you to talk with the ED if he is not from Minnesota.
Me:  "Are you sure about that?"
Hospital:  "Yes very sure."
Me:  "I am a physician - is there any way that I can talk directly physician-to-physician with an ED physician."
Hospital:  "No you can't.  You have to call the number on the back of the insurance card."

That was a precedent setting call for me.  I did not identify myself as a psychiatrist, but I have really never encountered this kind of administrative obstacle to medical care.  I viewed my question as an important one and one that an ED physician would probably know more about than me.  In that context there was something about an out of state resident not getting equal access to medical care.  I am sure it would be easier to get access in France or Germany than it was in Minnesota.  I collected the medical card and made a second call to the nurse triage line listed on the back of the call.  My experience with nurse triage lines is that they at least call the physicians on call and get some semblance of an answer to your question - even on the weekends.

Me:  Explaining the situation again in its entirety and giving all of the relevant insurance information both on and off the card.  The off card data included date of birth and three repeats of a call back number.  It was at that point the triage nurse said:
Triage RN:  "Well I am afraid I can't help you because you have to talk with a nurse who is licensed in the state where your relative resides.  But I will transfer you."
Me:  "OK"
Cricket sounds and bad muzak for about 5 minutes.
Triage RN (back on the line):  "The wait times are too long.  Let me just tell you that as long as he has no headaches, nausea, vomiting, visual changes or neurological symptoms - you can just watch him.  Bring him to the ED if any of those symptoms occur."
Me:  "OK - there is no imaging study given his age?"
Triage RN: "No".

As multiple posts on this blog can attest - I am openly critical of how business and government interests have rationed access to health care.  I had really never imagined obstacles to standard health care based on your state of residence.  I had never encountered a system that refused physician contact with another physician in their system.  I can see the gears turning on how to turn these calls into billable fees, even if it means a steep out-of-pocket payment by the patient.  But even in that case giving me the correct medical information is money in their pocket if it results in a CT scan.  Medical imaging generally covers about one-quarter of the operating budgets of hospitals these days.

For now it appears that after hours physician consultation may be rare and a sequence of calls based on legitimate concern needs to be answerable by a triage nurse's database or a visit to the emergency department.

And you better hope that you are in the right state.



George Dawson, MD, DFAPA




Supplementary (posted on August 23):

Getting back home and doing a little more research shows that both the Emergency Medicine (2) and Internal Medicine (1) literature say that age alone is an indication for a CT scan following a minor TBI.  UpToDate says that age 65 years of age or older is an indication.  The emergency medicine literature uses New Orleans Criteria suggesting an age of > 60 and the Canadian CT Rule suggesting an age of > 65 under CT if any criteria present.  According to these criteria - age alone is an indication for a CT scan.

1:  Randolf W. Evans.  Concussion and mild traumatic brain injury. In: UpToDate, Aminoff MJ, Moreira ME (Eds), UpToDate, Waltham, MA (Accessed on August 22, 2016). - see graphic 50743.

2:  Haydel M. Management of mild traumatic brain injury in the emergency department. Emerg Med Pract. 2012 Sep;14(9):1-24. Epub 2012 Jul 20. Review. PubMed PMID: 23101569. (full text online).


Attribution:

That's me walking on a dock in Lake Country.

Medicine to Psychiatry to Parking Lot: The Evolution Of Detox Over The Past 30 years

There is probably no better indicator of discriminatory rationing in the business run era of health care than the way substance users, alcoholics, and addicts are treated.  If you think about it - this is the ideal population to discriminate against.  In the severe situations where hospital detoxification is needed most of these folks are isolated and they have burned a lot of bridges.  They don't have a lot of friends and family members advocating for medical resources.  Most are unconcerned about their own health and many have significant medical morbidity associated with the addiction.  With any addiction, the tendency to continue the addicted states governs decision making so they enthusiastically leave medical facilities without addressing the problem as soon as a physician gives them clearance to go.  They are quite happy to keep bed occupancy and length of stay to the very minimum.  That is if they get admitted at all these days.

Back when I was in training as a medical student, I was fortunate to get most of my clinical training in large public facilities like county hospitals or VA hospitals.  In those days, patients with alcoholism or addictions who needed detoxification were admitted to Internal Medicine Services.  This was a great idea for several reasons.  Many people with addictions have significant medical comorbidity either independent of the addiction or due to it.  I saw many cases of acute pneumonia, pneumonia and meningitis, acute hepatitis, cirrhosis, pancreatitis, hepatic encephalopathy, delirium tremens, withdrawal seizures, and Wernicke's encephalopathy.  I don't think there is any better place in a hospital to address those problems than under the care of Internal Medicine specialists.  Until you have seen enough people critically ill and in withdrawal - it is difficult to appreciate the life-threatening aspects of intoxication or withdrawal from an addictive substance.  At some point in the mid to late 1980s, the detoxification landscape changed dramatically.  Suddenly a large number of those patients needing detox were sent to psychiatry services.  Only the obviously ill and delirious could get admitted to Medicine.  After the triage decision in the Emergency Department (ED) it was up to Psychiatry to sort out the problems and treat them as well as doing the detoxification.  There was also the development of county detox units, basically as a safer environment than the street, but offering little to no medical detoxification services.  If a patient went to a county detox unit and had a seizure there or became delirious - they could always be sent back to the ED.

A few years into my inpatient career. utilization reviewers started to deny the cost of care for anyone on my unit getting detox services.  That included people with the highest risk profile - depression, alcoholism, and suicidal ideation or behavior.  The primary rationale of these reviewers was that the patient did not require detoxification on an inpatient unit - even if they were in active withdrawal, taking high doses of detox medications, and had been discovered attempting suicide prior to admission.  The denial was based on an addiction or alcoholism and the fact that managed care companies had mandated that it was no longer an acceptable reason to treat somebody in a hospital.  The year was about 1990 and it was clear that this was a blanket denial of anyone with an addiction.  That had the predictable effect of inpatient psychiatry no longer being a resource for safe medical detoxification.  We are still dealing with the fallout from these business decisions 26 years later.  The fallout takes several forms including:

1.  A loss of infrastructure - there are no longer a significant number of Internists or Psychiatrists who routinely diagnose and treat withdrawal states and the associated addictions.  Most hospitals in any state do not have these services with the exception of the occasional person who is agitated or delirious in the ED and requires intubation and ICU support.  One of the frequent suggestions I hear about the current opioid epidemic is whether or not physicians are adequately trained in addictions.  With the loss of a detoxification infrastructure, I doubt that medical students and residents are seeing anywhere near the number of patients with addictions that they need to see relative to 30 years ago.

2.  A proliferation of inadequate detoxification facilities - a lot of the current facilities are run by counties and there is no medical aspect to treatment.  Decisions to get medical assistance may be made by someone with no medical background.  These facilities do not have environments that are managed to provide a calm and non-threatening atmosphere.  Many people admitted to them are fearful of the other patients and see the detoxification as a penalty.  They leave as soon as possible - even if they are still experiencing withdrawal symptoms.  Some of the facilities will only accept patients with a positive blood alcohol level by breathalyzer, and they discharge people when their estimated blood alcohol content reaches a certain level.  If you need detoxification from a sedative hypnotic or an opioid or several compounds -  you are out of luck.

City and county jails also double as detox facilities, in the same way that they double as psychiatric hospitals.  A common history is a patient on methadone or buprenorphine maintenance who is incarcerated, not given their usual maintenance medications and who is forced to go into acute withdrawal.  People who have been taking sedative hypnotics or using alcohol can also go into acute withdrawal that is potentially more serious.  Correctional facilities need systems in place to assure adequate and safe care for incarcerated individuals to prevent these acute withdrawal syndromes.  There are always a number of people with alcohol and drug use problems who die while they are incarcerated and as far as I can tell - these deaths are never investigated to determine if they received adequate medical and psychiatric care.

3.  A proliferation of "outpatient detox" - I can't really pinpoint when it became acceptable for patients with uncontrolled alcohol or drug use to suddenly manage their own detoxification using addictive drugs, but it is a common scenario these days.  Go into the ED with alcohol withdrawal and leave with a benzodiazepine to take on a scheduled basis.  Nobody should be too surprised if that medication is ingested at a higher than directed rate.  At times the entire bottle is taken on day 1.

4.  A disrupted spectrum of addiction care - apart from preventing life-threatening complications, the main reason for detoxification is to disrupt the cycle of addiction so that the affected person can get past all of the negative reinforcement (cravings, preoccupation, physical withdrawal symptoms) that keep the addiction going.  Without this modality, people are at home trying to cautiously taper off a drug or alcohol.  Many will go on for years without any success and they will be frustrated by the lack of abstinence or sobriety and give up.  Some with leave a clinic or ED with a supply of medication in order to try to detoxify themselves and realize that they are not able to take that medication on the suggested schedule to complete a safe detox.  Many will feel guilty or ashamed about going to AA or NA meetings while they are still using drugs or alcohol and give up.  Adequate detox avoids all of these problems with a rapid and safe approach to the initial stage of recovery from addiction.  

5.  The myth that business managers know what is best - the managerial class in America continues to run medicine without any knowledge of measurement, statistics, or quality.  In this case the logic seems obviously wrong.  Since the need for medical detoxification is an emergency it should be difficult to deny coverage for this condition.  That denial has been more or less routine and the cumulative denial has led to a serious degradation of services available for alcohol and drug use problems.

When I think about how medical treatment is supposed to work, every health plan should have adequate residential or hospital detox services for quality, safety and continuity of care.  Those facilities need to be more than holding tanks.  The environment has to be respectful, quiet, and comfortable where every patient feels safe and like they are being provided adequate care.  Active psychiatric consultation needs to occur because of the high comorbidity of psychiatric problems with addiction.  The current opioid epidemic has precipitated a discussion of improving the infrastructure to treat addiction.  That would not be too difficult since a large part of that infrastructure has been rationed out of existence in the last 20 years.

This sequence of events also has implications for all of the ideas about mandated physician education about opioid prescribing.  In some states the requirement is extensive and in many at this point it is mandated for licensure.  These mandates are shortsighted without the necessary infrastructure.  Addiction and detox services require administrative support and not administrative rationing.  Mandated education for physicians in not likely to do much good as long as they are sending addicted patients out with a bottle of medications and they end up detoxing in the parking lot.

It is time to drastically improve the treatment of all patients with alcohol and substance use disorders and stop the long-standing discrimination against them.      


George Dawson, MD, DFAPA