One of the big media stories today is about David Healy's address to the American Psychiatric Association's Psychiatric Services meeting. Like many of the psychiatrists turned critic his celebrity and notoriety status depend a lot of the amount of controversy that he is associated with and he comments on that in the opening remark. If you carefully read through this article, you will find that the financial conflicts of interest alluded to in the article are largely historical at this point. The elephant in the room for these critics is that practically all antidepressants are generics these days and they are no longer marketed by pharmaceutical companies.
I was an early adopter of maintaining clear boundaries with pharmaceutical companies and for the past 20 years or so - did not see detail salespeople, did not accept food and did not accept any gifts. On the other hand, I have always found pharmaceutical companies to be a rich source of data in addition to the usual FDA approved package insert. As an example, I am looking at a disc sitting on my desk right now entitled "Iloperidone unsolicited slides - for education use only." I gave a lecture on newer atypical anti psychotics several years ago and contacted the scientific divisions of three pharmaceutical companies looking for basic science data on the new drugs and they all supplied me with complete clinical trials data and basic science information on the receptor profiles that I wanted. I will also call them up with possible adverse events and get detailed information about that frequently via fax the same day.
Healy appeared to have made a controversial remark about psychiatrists committing "professional suicide" by their affiliation with pharmaceutical companies. In his previous remarks he make the comment about professional suicide as a preface to the second paragraph below:
"Healy noted further that when data surfaced showing a link between antidepressant use and risk of suicide in children, the APA issued a statement proclaiming that “we believe that antidepressants save lives.”
“What I believe they should have said is that the APA believes that psychiatrists can save lives because it takes expertise to manage the risks of risky pills,” he said; if psychiatrists’ only role were to dole out drugs, then less-trained physician’s assistants could easily replace them, he noted."
I have seen the comment on his blog at least 6 months ago and there should be complete agreement with this statement. Just in the past month I have had to diagnose and address drug induced liver disease, serotonin syndrome, eosinophilia, antidepressant associated hypertension, and spent a considerable larger amount of time making sure that antidepressants could be safely prescribed and that they were not making pre-existing medical problems worse. Recognizing those problems goes beyond the diagnostic process to coming up with a plan to monitor and treat it. A considerable amount of my time is, if not most of my time is spent managing side effects and protecting the health of my patients.
Although Healy takes positions that I would consider to be inaccurate, in this case he is dead on. It is professional suicide to collude with the idea that the treatment of any mental illness resides in a pill. Marketing genius maybe, but certainly not reality. Drugs don't treat and cure depression, psychiatrists do and it goes far beyond selecting a medication. Monitoring the patient for these complications and recognizing rare complications takes time and that time needs to be available - even in visits that are supposed to be focused on "medication management".
George Dawson, MD, DFAPA
Sunday, October 7, 2012
Confusion about Capitation versus Fee-For-Service versus National Health Care
This is from the Shrink Rap blog this morning the consensus is that capitated care is better than fee-for-service care. What is wrong with that picture?
Starting out with the much maligned fee-for-service (FFS) - most medical and psychiatric services are not delivered in that context. You can safely say that FFS, disappeared a long time ago. According to a 2012 Medscape survey of 24,216 physicians across 25 specialties only 4% worked in cash only or concierge style practices. That means that everyone else is subject to varying degrees of insurance company discounting. From my years of providing inpatient care for example, there is a standard DRG payment based on a global discharge or admission diagnosis. For the most common psychosis DRGs the standard payment is $4,500 no matter how long a person is stays in the hospital.
The same thing happens on the outpatient side. I have discussed this more extensively is a previous post. Looking at the commonest outpatient billing code - actual reimbursement for providing services can be as little as $22.45 per visit. In the case where bills are submitted with CPT codes (common to all of medicine) Medicare pays 50% of the usual and customary charge for psychiatry compared with 80% for the rest of Medicine. A lot depends on contracting arrangements since a contract can limit a psychiatrist to billing only a 90862 code and the company can also decide that they disagree that services were provided and either deny payment or demand repayment of a significant amount of money based on a review of the documentation.
The business adaptation to this on the hospital and managed care side (if they own the hospital) is to hire case managers to get patients out of the hospital within 3 or 4 days. Some of these systems have confabulated their own "guidelines" that allow them to do this that are totally independent of any professional standards. So if you are a managed care business and you own the hospital you are winning at two levels - you already shift the risk to the providers and hospitals by the Medicare style DRG payment and you do it a second time by insisting that they go along with the business decision to discharge the patient from the hospital.
Strictly speaking, the examples of discounted fees are technically not capitation. Discounted fees still allow for some elasticity within the system because there is still a fee paid per service event. Capitated systems of care like behavioral health carve outs can be set up to pay a set fee for managing a specific population. For example, a system of care is under contract for providing all services to a specific group of employees for a rate that is negotiated irrespective of actual patient visits.
The best way to understand capitated care is that it is designed to provide insurance companies a significant financial incentive for rationing care. That incentive comes directly out of the total amount of money available for health care spending Psychiatry, mental health, and addiction services were the easiest targets due to insitutionalized stigma, lack of a vocal constituency, and the political ineptness of psychiatrists. It is anybody's guess about how much a managed care company can make for denying or rationing care but some estimates of the margins have been as high as 20-40%.
One thing is for certain. Capitated care is not a comprehensive national health system. It takes hundreds of billions of dollars out of the health care system and diverts it to CEOs and stockholders. Contrary to the political opinion it does not contain the cost of health care inflation. One of the readers of the Shrink Rap blog pointed out that in a national system of health care you might be able to get an expensive medication like aripiprazole but you would have to wait longer. In our current system of capitated care if your managed care company decides - you will not be able to get it at all.
That is probably the best example of the difference.
George Dawson, MD, DFAPA
Starting out with the much maligned fee-for-service (FFS) - most medical and psychiatric services are not delivered in that context. You can safely say that FFS, disappeared a long time ago. According to a 2012 Medscape survey of 24,216 physicians across 25 specialties only 4% worked in cash only or concierge style practices. That means that everyone else is subject to varying degrees of insurance company discounting. From my years of providing inpatient care for example, there is a standard DRG payment based on a global discharge or admission diagnosis. For the most common psychosis DRGs the standard payment is $4,500 no matter how long a person is stays in the hospital.
The same thing happens on the outpatient side. I have discussed this more extensively is a previous post. Looking at the commonest outpatient billing code - actual reimbursement for providing services can be as little as $22.45 per visit. In the case where bills are submitted with CPT codes (common to all of medicine) Medicare pays 50% of the usual and customary charge for psychiatry compared with 80% for the rest of Medicine. A lot depends on contracting arrangements since a contract can limit a psychiatrist to billing only a 90862 code and the company can also decide that they disagree that services were provided and either deny payment or demand repayment of a significant amount of money based on a review of the documentation.
The business adaptation to this on the hospital and managed care side (if they own the hospital) is to hire case managers to get patients out of the hospital within 3 or 4 days. Some of these systems have confabulated their own "guidelines" that allow them to do this that are totally independent of any professional standards. So if you are a managed care business and you own the hospital you are winning at two levels - you already shift the risk to the providers and hospitals by the Medicare style DRG payment and you do it a second time by insisting that they go along with the business decision to discharge the patient from the hospital.
Strictly speaking, the examples of discounted fees are technically not capitation. Discounted fees still allow for some elasticity within the system because there is still a fee paid per service event. Capitated systems of care like behavioral health carve outs can be set up to pay a set fee for managing a specific population. For example, a system of care is under contract for providing all services to a specific group of employees for a rate that is negotiated irrespective of actual patient visits.
The best way to understand capitated care is that it is designed to provide insurance companies a significant financial incentive for rationing care. That incentive comes directly out of the total amount of money available for health care spending Psychiatry, mental health, and addiction services were the easiest targets due to insitutionalized stigma, lack of a vocal constituency, and the political ineptness of psychiatrists. It is anybody's guess about how much a managed care company can make for denying or rationing care but some estimates of the margins have been as high as 20-40%.
One thing is for certain. Capitated care is not a comprehensive national health system. It takes hundreds of billions of dollars out of the health care system and diverts it to CEOs and stockholders. Contrary to the political opinion it does not contain the cost of health care inflation. One of the readers of the Shrink Rap blog pointed out that in a national system of health care you might be able to get an expensive medication like aripiprazole but you would have to wait longer. In our current system of capitated care if your managed care company decides - you will not be able to get it at all.
That is probably the best example of the difference.
George Dawson, MD, DFAPA
Sunday, September 30, 2012
"Doctors don't label"
In a rare statement of clarity amid the usual sensational spin this comment jumped out at me:
"Doctors don't label...Doctors diagnose, take care of, and treat. That's not to say that something cannot be stigmatizing, but 'labeling' kind of gets right into the antipsychiatry component of it." William T. Carpenter, MD - Clinical Psychiatry News September 2012; p 3.
Dr. Carpenter is right and every psychiatrist knows it. Psychiatrists don't label. Psychiatrists diagnose. Psychiatrists are very aware of the limitations of diagnosis given the the sociocultural and medical contexts. The psychiatric orientation is to be helpful to patients and the diagnosis is the focus of that treatment. Furthermore, all psychiatric diagnosis and treatment is supposed to be confidential and there is no group of physicians who has tried to hold the line more against government and insurance companies eroding patient-physician confidentiality than psychiatrists.
A significant part of this article about the content of a letter from the Society for Humanistic Psychology (Division 32 of the American Psychological Association). Read the letter and draw your own conclusions. The points of contention listed in the letter have been exposed in several other media contexts. As I read through the letter there are several problems:
"This document was composed in recognition of, and with sensitivity to, the longstanding and congenial relationship between American psychologists and our psychiatrist colleagues."
I don't think that this is an accurate statement. When I started out in psychiatry and was in my third year of residency the American Psychological Association decided to get more aggressive politically and their target was basically American psychiatry. I won't rehash all of that ugliness but simply point out that things were far from congenial and in many areas remain problematic. Much of those political efforts were based on the idea that organized psychiatry had an inordinate amount of control over the treatment of mental illness. Any observer - biased or unbiased should recognize that psychiatrists and physicians in general have been marginalized and the American Psychiatric Association is politically ineffective and weak. Of course any other group of mental health providers is in the same boat.
"Given lack of consensus as to the “primary” causes of mental distress, this proposed change may result in the labeling of sociopolitical deviance as mental disorder."
This is a comment on the new DSM5 definition of a mental illness, specifically that the new definition does not explicitly say that deviant behavior and conflicts with society are not mental disorders. The current version states that these conflicts need to be the result of dysfunction within the individual. It is hard for me to see a situation where this is relevant to the practice of psychiatry. Is there really a case where I am going to diagnose a person in this situation with a mental disorder? Definitely not and the reason is that I have been confronted with the situation many times before and pointed out that the conflict was not the product of a mental illness. The authors here have focused primarily on a lower threshold for diagnosis and how they are not confident about the clinical decision making skills of practitioners - but do not comment on the threshold part of the definition.
"Increasing the number of people who qualify for a diagnosis may lead to excessive medicalization and stigmatization of transitive, even normative distress."
The risk of "medicalization" needs to be considered for a moment. What is "medicalization"? The implication of this letter at a practical level is that it involves an excessive use of medications. Suspending the poor quality of many of those studies for a moment, what is the real driver of medication use in today's practice environment? The minority of people taking any kind of psychiatric medication see psychiatrists. The managed care industry and the government are clearly the driving force. Current "evidence based" approaches are linked directly to medication use. A checklist diagnosis and rating scale approach has been used to rapidly treat patients with antidepressants in primary care settings. That approach alone has easily outpaced any DSM5 modifications. Direct to consumer drug advertising compounds the issue of getting as many people on medications as possible. You don't even have to read the DSM5 to see that medicalization has little to do with medical doctors. In fact, managed care companies would clearly like to replace as many doctors as possible with "prescribers" who can fill prescriptions according to these protocols. The pharmaceutical and managed care industries are far more interested in distilling psychiatric treatment down to a pill or a capsule than psychiatrists are.
The associated idea that psychiatrists may be the initiators of this medicalization or at least collude with it ignores psychiatric innovation that does not involve the prescription of medications. On this blog alone, I have posted excellent examples of work done by Greist and Gunderson on innovative and highly successful non medication approaches to significant problems. Dr. Greist's ideas have been presented to a wide audience that includes pharmaceutical companies. His ideas about how to make effective psychotherapy widely available have been successfully applied in other countries. Ignoring psychiatric innovation outside of psychopharmacology is a curious phenomena, but it definitely makes it easier to see psychiatrists as the "medicalizers". I am sure that both Greist and Gunderson would not see medications as the primary treatment for anxiety disorders or borderline personality disorder.
Once again, the focus on problems in the DSM5 leading to medicalization and stigmatization is clearly overemphasized. There is no group of people more aware of the limitations of the current diagnostic system than psychiatrists. There is no group of people better equipped to compensate for these deficiencies. There is no group of people more aware of the stigma of mental illness and addiction. Psychiatrists have a unique perspective in observing first hand how health care systems institutionalize stigma and use it to reduce the resources dedicated to treat these problems. There should be no doubt that the DSM5 is being produced in what is considered the best interest of the American Psychiatric Association. There should also be no doubt that the critiques of the process have their own interests and their opinions should be evaluated in that context.
George Dawson, MD, DFAPA
"Doctors don't label...Doctors diagnose, take care of, and treat. That's not to say that something cannot be stigmatizing, but 'labeling' kind of gets right into the antipsychiatry component of it." William T. Carpenter, MD - Clinical Psychiatry News September 2012; p 3.
Dr. Carpenter is right and every psychiatrist knows it. Psychiatrists don't label. Psychiatrists diagnose. Psychiatrists are very aware of the limitations of diagnosis given the the sociocultural and medical contexts. The psychiatric orientation is to be helpful to patients and the diagnosis is the focus of that treatment. Furthermore, all psychiatric diagnosis and treatment is supposed to be confidential and there is no group of physicians who has tried to hold the line more against government and insurance companies eroding patient-physician confidentiality than psychiatrists.
A significant part of this article about the content of a letter from the Society for Humanistic Psychology (Division 32 of the American Psychological Association). Read the letter and draw your own conclusions. The points of contention listed in the letter have been exposed in several other media contexts. As I read through the letter there are several problems:
"This document was composed in recognition of, and with sensitivity to, the longstanding and congenial relationship between American psychologists and our psychiatrist colleagues."
I don't think that this is an accurate statement. When I started out in psychiatry and was in my third year of residency the American Psychological Association decided to get more aggressive politically and their target was basically American psychiatry. I won't rehash all of that ugliness but simply point out that things were far from congenial and in many areas remain problematic. Much of those political efforts were based on the idea that organized psychiatry had an inordinate amount of control over the treatment of mental illness. Any observer - biased or unbiased should recognize that psychiatrists and physicians in general have been marginalized and the American Psychiatric Association is politically ineffective and weak. Of course any other group of mental health providers is in the same boat.
"Given lack of consensus as to the “primary” causes of mental distress, this proposed change may result in the labeling of sociopolitical deviance as mental disorder."
This is a comment on the new DSM5 definition of a mental illness, specifically that the new definition does not explicitly say that deviant behavior and conflicts with society are not mental disorders. The current version states that these conflicts need to be the result of dysfunction within the individual. It is hard for me to see a situation where this is relevant to the practice of psychiatry. Is there really a case where I am going to diagnose a person in this situation with a mental disorder? Definitely not and the reason is that I have been confronted with the situation many times before and pointed out that the conflict was not the product of a mental illness. The authors here have focused primarily on a lower threshold for diagnosis and how they are not confident about the clinical decision making skills of practitioners - but do not comment on the threshold part of the definition.
"Increasing the number of people who qualify for a diagnosis may lead to excessive medicalization and stigmatization of transitive, even normative distress."
The risk of "medicalization" needs to be considered for a moment. What is "medicalization"? The implication of this letter at a practical level is that it involves an excessive use of medications. Suspending the poor quality of many of those studies for a moment, what is the real driver of medication use in today's practice environment? The minority of people taking any kind of psychiatric medication see psychiatrists. The managed care industry and the government are clearly the driving force. Current "evidence based" approaches are linked directly to medication use. A checklist diagnosis and rating scale approach has been used to rapidly treat patients with antidepressants in primary care settings. That approach alone has easily outpaced any DSM5 modifications. Direct to consumer drug advertising compounds the issue of getting as many people on medications as possible. You don't even have to read the DSM5 to see that medicalization has little to do with medical doctors. In fact, managed care companies would clearly like to replace as many doctors as possible with "prescribers" who can fill prescriptions according to these protocols. The pharmaceutical and managed care industries are far more interested in distilling psychiatric treatment down to a pill or a capsule than psychiatrists are.
The associated idea that psychiatrists may be the initiators of this medicalization or at least collude with it ignores psychiatric innovation that does not involve the prescription of medications. On this blog alone, I have posted excellent examples of work done by Greist and Gunderson on innovative and highly successful non medication approaches to significant problems. Dr. Greist's ideas have been presented to a wide audience that includes pharmaceutical companies. His ideas about how to make effective psychotherapy widely available have been successfully applied in other countries. Ignoring psychiatric innovation outside of psychopharmacology is a curious phenomena, but it definitely makes it easier to see psychiatrists as the "medicalizers". I am sure that both Greist and Gunderson would not see medications as the primary treatment for anxiety disorders or borderline personality disorder.
Once again, the focus on problems in the DSM5 leading to medicalization and stigmatization is clearly overemphasized. There is no group of people more aware of the limitations of the current diagnostic system than psychiatrists. There is no group of people better equipped to compensate for these deficiencies. There is no group of people more aware of the stigma of mental illness and addiction. Psychiatrists have a unique perspective in observing first hand how health care systems institutionalize stigma and use it to reduce the resources dedicated to treat these problems. There should be no doubt that the DSM5 is being produced in what is considered the best interest of the American Psychiatric Association. There should also be no doubt that the critiques of the process have their own interests and their opinions should be evaluated in that context.
George Dawson, MD, DFAPA
Wednesday, September 26, 2012
Why antidepressants are not addictive
I recently noticed that a blogger posted his
theory on the addictive properties of antidepressants. He pointed out that
people get "psychologically addicted" and that using the term
"addiction" for physical addiction seemed too restrictive. His supporting evidence is a newspaper article about how Glaxo Smith Kline
dropped its claim on a patient information pamphlet for paroxetine saying that
the drug was "not addictive". David
Healy is quoted as saying "If there is withdrawal, then there is physical
dependence. There will be some people who will never be able to halt this
drug, there will be some for whom halting will not be awfully difficult and
some for whom it is a real issue". The article goes on to say that although
SSRIs are not like opiates they are "more comparable to the
benzodiazepines such as diazepam, which is now prescribed only with great
caution because of withdrawal problems".
Working in the addiction field this entire line of thinking
is rhetorical. There is significant psychiatric comorbidity in people with
addictions with anywhere from 40-75% having co-occurring disorders. Most of
those co-occurring disorders are anxiety disorders and depression and they are well
known triggers for relapse as well as initiating drug and alcohol use in the
first place. Contrary to public denial, addictive disorders have huge
liabilities in terms of morbidity and they are often lethal illnesses. My goal is to reduce the risk of relapse by
treating the co-occurring disorder while the person is being treated for
addiction. SSRI medications are one of the mainstays of treating anxiety and
depression these days. They are effective medications. I would not be
prescribing them if they caused "psychological addiction". Furthermore,
many treatment programs for addiction teach the concept of cross addiction and
nobody studying that concept would want to take an SSRI if it caused any kind
of addiction.
A better starting point would be to look at more
comprehensive definition
of what an addiction is. That starting point would be the October 2011
definition issued by the American Society of Addiction Medicine. Paragraph 2 of the short definition will
suffice and reading those four lines should make it very clear that the use of
antidepressant medications does not lead to addiction. The real hallmark of
addictions is uncontrolled use and there is no evidence that modern antidepressants
are used in an uncontrolled manner. Additional
evidence is that antidepressants have absolutely no street value and therefore
are in the majority of 34 million chemical compounds listed in Chem Abstracts
of which only about 322 are addicting.
If your doctor has recommended that you take an
antidepressant medication certainly be aware of the fact that there may be
discontinuation symptoms. Discontinuation symptoms are not an addiction. Needing to take an antidepressant for a
chronic mood or anxiety disorder is not an addiction. Contrary to Dr. Healy's opinion there are a number of nonpsychiatric medications can be discontinued and cause severe discontinuation symptoms. The term "physical dependence" suggests an addiction or the inappropriate use of a potentially addicting drug where in fact that is not the case with antidepressants. Comparing antidepressants to other clearly addictive
compounds like benzodiazepines or opioids is not an accurate comparison across
any dimension. I agree that any person considering an antidepressant drug needs to be aware of the fact that mild to
moderate symptoms can respond to psychotherapy as well as medication. ANY medication can lead to rare but very serious
complications. Any person considering treatment with medications needs to be working with a physician who is skilled in the use of these medications and who can address any potential side effects. My personal experience in
treating people who have severe anxiety and depression is that they reach a
point that anyone with a severe chronic illness reaches in making a decision
about medication. That point generally involves asking themselves: "What
else am I going to do?".
As physicians we can never minimize the importance of that
question.
Response to Dr. Willenbring
I wrote this response to Mark Willenbring's post on his blog. I reposted it here because the links do not work in the reply section of his blog in case anyone is interested in the references:
------------------------------------------------------------------------------------------------------------
I generally agree with what you are saying. I think the no fault aspect of the illness is
very difficult for many to grasp - most importantly the policy makers and
health plan administrators. I think it
is captured very well in the latest ASAM definition. I think that Sellman’s Top Ten list and the
responses to it are also instructive especially item 7 “Come back when you are
motivated” is no longer an acceptable therapeutic response’ is part of your
message.
From a systems standpoint, the lack of a full array of
services to treat addiction is striking.
Over the course of my career I have seen detox services essentially
moved to mental health units and then to the street. I wrote a post about this several weeks ago
that was read by current detox staff who agreed with it. It is hard to believe that in many if not
most cases people with addictions are sent home from the ED, sent home with a
handful of benzodiazepines, or sent to a facility with no medical coverage for
a complex detox process. I think the
test of any health care system is whether a primary care doc can ask themselves
if they have a safe detox procedure for any of their regular patients who are addicted
to opioids and benzodiazepines and needs surgery.
Medical systems in general have a very poor attitude toward
people with addictions. I think that
these healthcare systems and their personnel are much more likely to take a
moralistic attitude toward addicts and not treat them well. I have seen that theme repeated across
multiple care settings. Many rationed
care settings disproportionately reduce resources necessary to treat addiction. I think it is safe to say that most
cardiology patients with suspicious chest pain get a $10,000 evaluation and
reassurance or appropriate treatment.
Most patients with addictions do not even get a $300 evaluation. They may actually see a physician who provides
them with medications that fuel their addiction. Institutionalized stigma plays a big role in
that. There are no billboards in the
Twin Cities advertising state-of-the-art addiction treatment. There are many advertisements for heart
centers.
I am less pessimistic about the effects of 12-step recovery
and time in a residential setting whether it is a high end recovery facility or
a state hospital. I think if you are in
a setting where there is no active treatment or sober environment you are
probably wasting your time. I have seen
people who were declared hopeless recover with time away from alcohol and drugs
on the order of months. Vaillant’s study
of severe alcoholism is a great example of the different paths to recovery and
there are many. His subsequent analysis
of how AA might work suggests that affiliation rather than blaming may be the
most curative element. AA is difficult
to study but I think that the message is positive and embodied in #3 of the Twelve Traditions. Up to that point the founders were looking at
the issue of exclusion but decided against it because alcoholism was a life
threatening disease and they could turn nobody away.
Sunday, September 23, 2012
What replaces DSM5? Whither RDoC?
"However, in antedating contemporary neuroscience research the current diagnostic system is not informed by recent breakthroughs in genetics; and molecular, cellular, and systems neuroscience. Indeed it would have been surprising if the clusters of complex behaviors identified clinically were to map on a one-to-one basis onto specific genes or neurobiological systems." NIMH 2011.
With the thorough politicization of the DSM5 and the dichotomous debates in the media it is surprising that nobody talked about what is in the works to replace it at the largest government funded think tank - The National Institute of Mental Health (NIMH). The proposed solutions in the media were generally to do nothing or to let a wide variety of professionals have input into criteria that have essentially been static for the past 30 years. There was very little comment about how the DSM5 is not a very good framework for incorporating recent scientific discoveries from brain imaging, molecular biology and genomics in addition to the typical subjective descriptions of each disorder. That is where NIMH's Research Domain Criteria (RDoC) come in.
Looking at the "Draft Research Domain Criteria Matrix" - it is hard to envision a standard 60 (or usually 30) minute clinical interview as a starting point for diagnosis or treatment. For example, with an initial episode of psychosis, there will probably be a lot more work done trying to identify cognitive endophenotypes or other transitional phenotypes within the current subjectively derived domains. A very conservative estimate suggests that this alone will take take least one hour of testing. There will probably need to be a lot of time and effort expended on determining when a person is testable. An RDoC diagnosis will be both time and resource intensive. It won't be a template or a checklist.
I am sure that the antipsychiatry/myth of mental illness crowd and some of the thinly veiled variants of this philosophy will be disappointed. After all, this is a diagnostic approach that directly assails one of the most typical arguments from them: "There is no "test" for mental illness." When the RDoC comes to fruition there will not just be one test. There will be many tests.
Like most things psychiatric, the biggest threat to the realization of a more comprehensive diagnostic system for our most complex illnesses is not the obvious detractors. It is the current political culture that applies junk science to the management of the health care system. It remains an incredible fact that political ideology and not medical science dictates medical treatment in this country. The current political consensus is that psychiatric care (like medical care) can be managed for both cost and quality by companies who can profit by rationing care. The care they ration the most is for the treatment of mental illnesses and addictions.
Will an Accountable Care Organization (ACO) in the future spend what it necessary to thoroughly evaluate an initial episode of psychosis if it takes as many or more resources than Cardiology currently uses to assess heart disease? The answer to that lies in whether the stigma against mental illness and addictions in health care and governing organizations can be overcome. Despite all of the lip service - it is that stigma that supports the current system of care that is predominately brief hospitalizations orchestrated by case managers and 15 minute "medication management" approaches to the treatment of mental illness.
You can't implement an RDoC in that environment.
George Dawson, MD, DFAPA
With the thorough politicization of the DSM5 and the dichotomous debates in the media it is surprising that nobody talked about what is in the works to replace it at the largest government funded think tank - The National Institute of Mental Health (NIMH). The proposed solutions in the media were generally to do nothing or to let a wide variety of professionals have input into criteria that have essentially been static for the past 30 years. There was very little comment about how the DSM5 is not a very good framework for incorporating recent scientific discoveries from brain imaging, molecular biology and genomics in addition to the typical subjective descriptions of each disorder. That is where NIMH's Research Domain Criteria (RDoC) come in.
Looking at the "Draft Research Domain Criteria Matrix" - it is hard to envision a standard 60 (or usually 30) minute clinical interview as a starting point for diagnosis or treatment. For example, with an initial episode of psychosis, there will probably be a lot more work done trying to identify cognitive endophenotypes or other transitional phenotypes within the current subjectively derived domains. A very conservative estimate suggests that this alone will take take least one hour of testing. There will probably need to be a lot of time and effort expended on determining when a person is testable. An RDoC diagnosis will be both time and resource intensive. It won't be a template or a checklist.
I am sure that the antipsychiatry/myth of mental illness crowd and some of the thinly veiled variants of this philosophy will be disappointed. After all, this is a diagnostic approach that directly assails one of the most typical arguments from them: "There is no "test" for mental illness." When the RDoC comes to fruition there will not just be one test. There will be many tests.
Like most things psychiatric, the biggest threat to the realization of a more comprehensive diagnostic system for our most complex illnesses is not the obvious detractors. It is the current political culture that applies junk science to the management of the health care system. It remains an incredible fact that political ideology and not medical science dictates medical treatment in this country. The current political consensus is that psychiatric care (like medical care) can be managed for both cost and quality by companies who can profit by rationing care. The care they ration the most is for the treatment of mental illnesses and addictions.
Will an Accountable Care Organization (ACO) in the future spend what it necessary to thoroughly evaluate an initial episode of psychosis if it takes as many or more resources than Cardiology currently uses to assess heart disease? The answer to that lies in whether the stigma against mental illness and addictions in health care and governing organizations can be overcome. Despite all of the lip service - it is that stigma that supports the current system of care that is predominately brief hospitalizations orchestrated by case managers and 15 minute "medication management" approaches to the treatment of mental illness.
You can't implement an RDoC in that environment.
George Dawson, MD, DFAPA
Saturday, September 22, 2012
Concentration of Effort, Academics, and Managed Care
I follow the Nephron Power blog because I have maintained a life long interest in Nephrology or at least since I found out what it was in Medical School. The conventional wisdom at the time was "Oh you're going into psychiatry - take as many medicine electives as possible because you will never have the chance to do medicine again." If there are any medical students reading this - I ended up doing another 22 years of following renal function, treating people who were delirious and in renal failure, treating manic patients who were in renal failure waiting for a kidney transplant, and consulting with Nephrologists. I can say without a doubt that the Nephrologists who I worked with are some of the brightest, most thoughtful and hardest working people I have ever known.
I still consider the Renal Service where I worked in medical school to be the model for academic medicine and how to teach medical students and residents. It was located in two adjacent hospitals and headed up by a cranky old guy. I say "old" realizing that he was probably about the same age that I am right now and he had the appearance of being cranky like a lot of old guys can get. You could tell he was very bright, very interested and not above giving the medical students a hard time. He made sure that on all of the consults we had conducted the appropriate "liquid biopsy" by performing our own urinalyses on patients we were seeing.
We rounded three times a day seeing all of the hospitalized patients in the morning, clinic patients in the afternoon, and hospital consults in the evening and at night. My last action as a medical student was staffing two Renal Medicine consults at about 8PM the night before I graduated. The other team members included another two attendings, two fellows, three Internal Medicine residents, and another medical student. The physical layout of the service was two hospital wings and a very busy clinic with a separate day for a Hypertension clinic. The hospital service was in the same hospital as the transplant team and we would also care for patients with transplant complications.
The atmosphere on this service was electric. Everyone was on time, interested, bright, academic and effective. To this day - I consider this team from the 1980s to be the prototype for what a teaching service in a Medical School should be and in many ways how serious medicine should be provided. When I left the hospital that night after the last two consults staffings of my medical student career I can remember thinking - should I have gone into medicine and become a nephrologist? My fantasy in psychiatry became to recreate this model or at least parts of it in psychiatry.
Flash forward 26 years. Most people would be fairly surprised to find out that you can come close to my fantasy in very few psychiatric units. The patient flow into and out of many psychiatric units generally does not depend on academic considerations like providing the best medical and psychiatric care to patients. In most cases patient flow does not depend on the judgment of psychiatrists. My ability to care for patients with the most severe illnesses did not come about because there is an elite cadre of psychiatrists who are academically interested and have the necessary resources to provide that level of care. It came about because the system where I worked needed a place to put these folks and I happened to be a psychiatrist who was interested in all of their problems.
I got very close to recreating at least the inpatient side of my old Renal Medicine service, but these days there are just too many administrative problems along the way. It is impossible to take a learned approach to medicine and psychiatry with administrators breathing down your neck about an absurdly short length of stay. It is a clash of paradigms and as far as I can tell the administrators have won. You cannot possibly address complex problems when someone is telling you that the only reason a patients should be in the hospital is that they are "suicidal" or "homicidal" - both very loosely defined business terms for getting the patient out in time to capture about a 20% profit on the DRG payment. Let's suspend the reality that this person is just too ill to function or that their illness has created an impossible situation at home or they are not able to care for their new medical diagnoses until they have recovered their cognition to some extent.
If you are really interested in a rigorous approach to tough problems these days you will run afoul of a huge managed care infrastructure that is there to process patients in and out of hospitals based almost entirely on business decisions. That makes life a lot less interesting for physicians and a lot more frustrating for patients. Patients coming out of the managed care environment have an almost universal experience that they were hardly seen in the hospital and when they were, there was not a lot of interest in solving their problems. They end up saying what they think people want to hear in order to be released and after they have been discharged realize that nothing has changed.
In the final analysis these are contrasting models but nobody pays much attention to the contrast. An academic full spectrum of care model versus a severely rationed model where care is based on an administrators notion of "dangerousness". Clinicians aware of the full spectrum of illness, grappling with all of the nuances and offering the necessary care versus a doctor sitting in an office prescribing pills as fast as they can.
That is what we are talking about and in that context - I will take the Renal Service any day.
George Dawson, MD, DFAPA
I still consider the Renal Service where I worked in medical school to be the model for academic medicine and how to teach medical students and residents. It was located in two adjacent hospitals and headed up by a cranky old guy. I say "old" realizing that he was probably about the same age that I am right now and he had the appearance of being cranky like a lot of old guys can get. You could tell he was very bright, very interested and not above giving the medical students a hard time. He made sure that on all of the consults we had conducted the appropriate "liquid biopsy" by performing our own urinalyses on patients we were seeing.
We rounded three times a day seeing all of the hospitalized patients in the morning, clinic patients in the afternoon, and hospital consults in the evening and at night. My last action as a medical student was staffing two Renal Medicine consults at about 8PM the night before I graduated. The other team members included another two attendings, two fellows, three Internal Medicine residents, and another medical student. The physical layout of the service was two hospital wings and a very busy clinic with a separate day for a Hypertension clinic. The hospital service was in the same hospital as the transplant team and we would also care for patients with transplant complications.
The atmosphere on this service was electric. Everyone was on time, interested, bright, academic and effective. To this day - I consider this team from the 1980s to be the prototype for what a teaching service in a Medical School should be and in many ways how serious medicine should be provided. When I left the hospital that night after the last two consults staffings of my medical student career I can remember thinking - should I have gone into medicine and become a nephrologist? My fantasy in psychiatry became to recreate this model or at least parts of it in psychiatry.
Flash forward 26 years. Most people would be fairly surprised to find out that you can come close to my fantasy in very few psychiatric units. The patient flow into and out of many psychiatric units generally does not depend on academic considerations like providing the best medical and psychiatric care to patients. In most cases patient flow does not depend on the judgment of psychiatrists. My ability to care for patients with the most severe illnesses did not come about because there is an elite cadre of psychiatrists who are academically interested and have the necessary resources to provide that level of care. It came about because the system where I worked needed a place to put these folks and I happened to be a psychiatrist who was interested in all of their problems.
I got very close to recreating at least the inpatient side of my old Renal Medicine service, but these days there are just too many administrative problems along the way. It is impossible to take a learned approach to medicine and psychiatry with administrators breathing down your neck about an absurdly short length of stay. It is a clash of paradigms and as far as I can tell the administrators have won. You cannot possibly address complex problems when someone is telling you that the only reason a patients should be in the hospital is that they are "suicidal" or "homicidal" - both very loosely defined business terms for getting the patient out in time to capture about a 20% profit on the DRG payment. Let's suspend the reality that this person is just too ill to function or that their illness has created an impossible situation at home or they are not able to care for their new medical diagnoses until they have recovered their cognition to some extent.
If you are really interested in a rigorous approach to tough problems these days you will run afoul of a huge managed care infrastructure that is there to process patients in and out of hospitals based almost entirely on business decisions. That makes life a lot less interesting for physicians and a lot more frustrating for patients. Patients coming out of the managed care environment have an almost universal experience that they were hardly seen in the hospital and when they were, there was not a lot of interest in solving their problems. They end up saying what they think people want to hear in order to be released and after they have been discharged realize that nothing has changed.
In the final analysis these are contrasting models but nobody pays much attention to the contrast. An academic full spectrum of care model versus a severely rationed model where care is based on an administrators notion of "dangerousness". Clinicians aware of the full spectrum of illness, grappling with all of the nuances and offering the necessary care versus a doctor sitting in an office prescribing pills as fast as they can.
That is what we are talking about and in that context - I will take the Renal Service any day.
George Dawson, MD, DFAPA
Saturday, September 15, 2012
More On Homicide Prevention
As the number of mass homicides becomes even more noticeable it is getting some attention in the psychiatric press. This months Psychiatric News has a story that looks at the issue of "explanations" for mass killings. There were a couple of new terms that I was not familiar with such as "rampage violence" or "rampage", "autogenic", or "pseudo-commando" killings. The perspective in the article was generally public health research or the perspective of forensic psychiatrists. Inconsistencies were apparent such as:
"... Much research has shown that mental illness in the absence of substance abuse does not lead to violence and that most crimes are committed by people who have not been diagnosed with mental illness."
Followed by:
"Even when behavior reaches a level troubling to family or neighbors, getting an affected individual into treatment is difficult, especially in a society that highly values individual liberty..."
Are they referring only to those people who are abusing substances or only those people who become violent as a result of mental illness? My experience is that both categories are important and that is illustrated within the same article that refers to a study of five "pseudo-commando" murders where common traits were noted including the fact that all of the subjects were "suspicious, resentful, narcissistic, and often paranoid".
The overall tone of the article is that we may be too focused on mass homicide because only a small number of people were killed in these incidents compared to the 30 to 40 people per day who die from homicide and that violence prediction may be a futile approach. There is also commentary on why neither the Democrats or Republicans want to comment on this issue. An uncritical statement about the "support for gun ownership" being at an all-time high is included in the same paragraph. Like most things political in the US, all you have to do is follow the money.
The same issue was covered in the September issue of Psychiatric Times. Lloyd Sederer, MD takes the position that apathy fueled the lack of a sea change in gun control following the incident when Congresswomen Gifford was shot and several people at that same event were killed. He includes an apathetic quote from Jack Kerouac and a nonviolent activist quote from Gandhi. Allen Frances, MD makes the reasonable observation that understanding the psychology of a mass killer will not prevent mass homicide, but proceeds to stretch that into the fact that this is a gun issue:
"We must accept the fact that a small cohort of deranged and disaffected potential mass murderers will always exist undetected in our midst."
and
"The largely unnoticed elephant in the room is how astoundingly easy it is for the killers to buy supercharged firearms and unlimited rounds of ammo. The ubiquity of powerful weaponry is what takes the US such a dangerous place to live."
He goes on to suggest that there are only two choices in this matter: accept mass murder as a way of life or adopt sane gun policies with the rest of the civilized world.
I don't think that gun laws are the best or only approach. The idea that "supercharged" firearms are the culprit here or the extension to banning assault weapons as the solution misses the obvious fact that even common widely available firearms - shotguns and handguns are highly lethal. Anyone armed with those weapons alone would be unstoppable in a mass shooting situation. Secondly, the effects of stringent firearms laws have mixed results. The mass shooting in Norway is an example of how tight firearm regulation can be circumvented. It is well known that there are a massive amount of firearms under private possession in the US, making the effect of firearm legislation even less likely. There are also the cases of heavily armed citizenry with only a fraction of the gun homicides that we have in the US. Michael Moore's comparison of the US with Canada in "Bowling for Columbine" comes to mind.
The previous posts on this blog suggest clear reasons why gun ownership is at an all-time high. The problem is that much can be done apart from the gun ownership issue and the solutions are available from psychiatrists who are used to assessing and treating people with mental illness, severe personality disorders, threatening behavior, or history of violent or aggressive behavior. The critical dimension that is not covered is the issue of prevention and the necessity of an open discussion about homicide and how to prevent it. Education about markers that are associated with mass homicide is useful, but the focus needs to be on how to help the person who starts to experience homicidal ideation before they lose control. That is also consistent with a humanistic approach to the problem. I have treated many "deranged and disaffected potential mass murderers" who went back to their families and back to work. We need a culture that is much more savvy about the origins of violence and aggression. It is too easy to say that this behavior is due to "evil" and maintain attitudes consistent with that approach. Time to develop research on the prevention of mass homicide, identify the individuals at risk, and offer effective treatment.
George Dawson, MD, DFAPA
Aaron Levin. Experts again seek explanations for mass killings. Psychiatric News 2012 (47)17: 1,20.
Lloyd I. Sederer. The enemy is apathy. Psychiatric Times 2012 (29)9: 1-2.
Allen Frances. Mass murderers, madness, and gun control. Psychiatric Times 2012 (29)9:1-2.
"... Much research has shown that mental illness in the absence of substance abuse does not lead to violence and that most crimes are committed by people who have not been diagnosed with mental illness."
Followed by:
"Even when behavior reaches a level troubling to family or neighbors, getting an affected individual into treatment is difficult, especially in a society that highly values individual liberty..."
Are they referring only to those people who are abusing substances or only those people who become violent as a result of mental illness? My experience is that both categories are important and that is illustrated within the same article that refers to a study of five "pseudo-commando" murders where common traits were noted including the fact that all of the subjects were "suspicious, resentful, narcissistic, and often paranoid".
The overall tone of the article is that we may be too focused on mass homicide because only a small number of people were killed in these incidents compared to the 30 to 40 people per day who die from homicide and that violence prediction may be a futile approach. There is also commentary on why neither the Democrats or Republicans want to comment on this issue. An uncritical statement about the "support for gun ownership" being at an all-time high is included in the same paragraph. Like most things political in the US, all you have to do is follow the money.
The same issue was covered in the September issue of Psychiatric Times. Lloyd Sederer, MD takes the position that apathy fueled the lack of a sea change in gun control following the incident when Congresswomen Gifford was shot and several people at that same event were killed. He includes an apathetic quote from Jack Kerouac and a nonviolent activist quote from Gandhi. Allen Frances, MD makes the reasonable observation that understanding the psychology of a mass killer will not prevent mass homicide, but proceeds to stretch that into the fact that this is a gun issue:
"We must accept the fact that a small cohort of deranged and disaffected potential mass murderers will always exist undetected in our midst."
and
"The largely unnoticed elephant in the room is how astoundingly easy it is for the killers to buy supercharged firearms and unlimited rounds of ammo. The ubiquity of powerful weaponry is what takes the US such a dangerous place to live."
He goes on to suggest that there are only two choices in this matter: accept mass murder as a way of life or adopt sane gun policies with the rest of the civilized world.
I don't think that gun laws are the best or only approach. The idea that "supercharged" firearms are the culprit here or the extension to banning assault weapons as the solution misses the obvious fact that even common widely available firearms - shotguns and handguns are highly lethal. Anyone armed with those weapons alone would be unstoppable in a mass shooting situation. Secondly, the effects of stringent firearms laws have mixed results. The mass shooting in Norway is an example of how tight firearm regulation can be circumvented. It is well known that there are a massive amount of firearms under private possession in the US, making the effect of firearm legislation even less likely. There are also the cases of heavily armed citizenry with only a fraction of the gun homicides that we have in the US. Michael Moore's comparison of the US with Canada in "Bowling for Columbine" comes to mind.
The previous posts on this blog suggest clear reasons why gun ownership is at an all-time high. The problem is that much can be done apart from the gun ownership issue and the solutions are available from psychiatrists who are used to assessing and treating people with mental illness, severe personality disorders, threatening behavior, or history of violent or aggressive behavior. The critical dimension that is not covered is the issue of prevention and the necessity of an open discussion about homicide and how to prevent it. Education about markers that are associated with mass homicide is useful, but the focus needs to be on how to help the person who starts to experience homicidal ideation before they lose control. That is also consistent with a humanistic approach to the problem. I have treated many "deranged and disaffected potential mass murderers" who went back to their families and back to work. We need a culture that is much more savvy about the origins of violence and aggression. It is too easy to say that this behavior is due to "evil" and maintain attitudes consistent with that approach. Time to develop research on the prevention of mass homicide, identify the individuals at risk, and offer effective treatment.
George Dawson, MD, DFAPA
Aaron Levin. Experts again seek explanations for mass killings. Psychiatric News 2012 (47)17: 1,20.
Lloyd I. Sederer. The enemy is apathy. Psychiatric Times 2012 (29)9: 1-2.
Allen Frances. Mass murderers, madness, and gun control. Psychiatric Times 2012 (29)9:1-2.
Borderline Personality Disorder - DBT versus GPM
I just got back from a Mayo Clinic CME course "Clinical Management of Borderline Personality Disorder". I went to see John G. Gunderson, MD. He and I go way back in a peripheral sort of way to the days before the Internet. About 20 years ago I sent him a letter and he mailed me a copy of his "Diagnostic Interview for Borderlines." That was about three years after Marsha Linehan mailed me a rough copy of her research protocol for Dialectical Behavior Therapy. I like to see and hear from the experts.
The course was excellent and the logical summation of work done in this field for the past two decades. It was accessible and the faculty that included Dr. Gunderson and Brian Palmer, MD were enthusiastic and optimistic about treatment outcomes. Dr. Gunderson pointed out that sampling bias has led to therapeutic nihilism and stigmatization in the past and that more recent outcome studies show very positive results. The basic tenets of therapy that you learn in psychiatry school can go a long way. Therapeutic neutrality, and active interest in with the patient has to say, the therapeutic alliance, and technical skill with specific interventions are common elements in working with patients across all diagnostic categories. If the diagnosis is accurate psychopharmacology is a secondary intervention. The primary focus is psychotherapy and case management.
One of the significant points in the presentation was the concept of General Psychiatric Management (GPM) in the treatment of borderline personality disorder. In the years since I received the DBT manual, in many areas that therapy has become the de facto standard of care for borderline personality disorder. There is research evidence that it is effective. DBT treatment programs seem to have popped up everywhere in the past decade. My experience in inpatient units led me to observe that many of these patients seem to have been misdiagnosed or DBT was being applied to the wrong diagnosis. There are fairly specific selection criteria for DBT, but it seems that anyone with a difficult problem was being put in a DBT program.
Dr. Gundersen referenced an article in the American Journal of Psychiatry comparing GPM versus DBT. General Psychiatric Management is a variation of what we used to call supportive psychotherapy and it was defined by the researchers as:
"General psychiatric management was implemented as a comprehensive approach to borderline personality disorder, developed and manualized for this trial, consisting of psychodynamic psychotherapy, case management, and pharmacotherapy (P.S. Links, Y. Bergmans, J. Novick, J. LeGris, unpublished 2009 manuscript). The psychotherapeutic model in this approach emphasized the relational aspects of the disorder and focused on disturbed attachment patterns and the enhancement of emotion regulation in relationships. Case management strategies were integrated into weekly individual sessions. No restrictions were placed on ancillary pharmacotherapy in either condition; in general, pharmacotherapy was based on a symptom-targeted approach but prioritized mood lability, impulsivity, and aggressiveness as presented in APA guidelines (16)." (see link below to McMain 2012)"
The study showed that the outcomes of both treatment modalities across several outcome measures (suicidal and non-suicidal self injurious behavior, depression, anger, interpersonal functioning) were comparable. GPM was delivered as once a week hourly psychotherapy with additional case management and coordination of care. This is important research because the logical extension of this research is to look at ways to improve functional capacity as well as symptomatology.
Take a look at the references and attend the seminar in the future if you have the chance.
George Dawson, MD, DFAPA
John G. Gunderson and Brian A. Palmer. Clinical Management of Borderline Personality Disorder. Mayo Clinic CME, September 14, 2012.
McMain SF, Links PS, Gnam WH, Guimond T, Cardish RJ, Korman L, Streiner DL. A randomized trial of dialectical behavior therapy versus general psychiatric management for borderline personality disorder. Am J Psychiatry. 2009 Dec;166(12):1365-74. Epub 2009 Sep 15.
McMain SF, Guimond T, Streiner DL, Cardish RJ, Links PS. Dialectical behavior therapy compared with general psychiatric management for borderline personality disorder: clinical outcomes and functioning over a 2-year follow-up. Am J Psychiatry. 2012 Jun;169(6):650-61
The course was excellent and the logical summation of work done in this field for the past two decades. It was accessible and the faculty that included Dr. Gunderson and Brian Palmer, MD were enthusiastic and optimistic about treatment outcomes. Dr. Gunderson pointed out that sampling bias has led to therapeutic nihilism and stigmatization in the past and that more recent outcome studies show very positive results. The basic tenets of therapy that you learn in psychiatry school can go a long way. Therapeutic neutrality, and active interest in with the patient has to say, the therapeutic alliance, and technical skill with specific interventions are common elements in working with patients across all diagnostic categories. If the diagnosis is accurate psychopharmacology is a secondary intervention. The primary focus is psychotherapy and case management.
One of the significant points in the presentation was the concept of General Psychiatric Management (GPM) in the treatment of borderline personality disorder. In the years since I received the DBT manual, in many areas that therapy has become the de facto standard of care for borderline personality disorder. There is research evidence that it is effective. DBT treatment programs seem to have popped up everywhere in the past decade. My experience in inpatient units led me to observe that many of these patients seem to have been misdiagnosed or DBT was being applied to the wrong diagnosis. There are fairly specific selection criteria for DBT, but it seems that anyone with a difficult problem was being put in a DBT program.
Dr. Gundersen referenced an article in the American Journal of Psychiatry comparing GPM versus DBT. General Psychiatric Management is a variation of what we used to call supportive psychotherapy and it was defined by the researchers as:
"General psychiatric management was implemented as a comprehensive approach to borderline personality disorder, developed and manualized for this trial, consisting of psychodynamic psychotherapy, case management, and pharmacotherapy (P.S. Links, Y. Bergmans, J. Novick, J. LeGris, unpublished 2009 manuscript). The psychotherapeutic model in this approach emphasized the relational aspects of the disorder and focused on disturbed attachment patterns and the enhancement of emotion regulation in relationships. Case management strategies were integrated into weekly individual sessions. No restrictions were placed on ancillary pharmacotherapy in either condition; in general, pharmacotherapy was based on a symptom-targeted approach but prioritized mood lability, impulsivity, and aggressiveness as presented in APA guidelines (16)." (see link below to McMain 2012)"
The study showed that the outcomes of both treatment modalities across several outcome measures (suicidal and non-suicidal self injurious behavior, depression, anger, interpersonal functioning) were comparable. GPM was delivered as once a week hourly psychotherapy with additional case management and coordination of care. This is important research because the logical extension of this research is to look at ways to improve functional capacity as well as symptomatology.
Take a look at the references and attend the seminar in the future if you have the chance.
George Dawson, MD, DFAPA
John G. Gunderson and Brian A. Palmer. Clinical Management of Borderline Personality Disorder. Mayo Clinic CME, September 14, 2012.
McMain SF, Links PS, Gnam WH, Guimond T, Cardish RJ, Korman L, Streiner DL. A randomized trial of dialectical behavior therapy versus general psychiatric management for borderline personality disorder. Am J Psychiatry. 2009 Dec;166(12):1365-74. Epub 2009 Sep 15.
McMain SF, Guimond T, Streiner DL, Cardish RJ, Links PS. Dialectical behavior therapy compared with general psychiatric management for borderline personality disorder: clinical outcomes and functioning over a 2-year follow-up. Am J Psychiatry. 2012 Jun;169(6):650-61
Thursday, September 13, 2012
Medscape Has Not Stopped Anonymous Postings
I had to put this comment here because my attempt to post it on the Psychiatric Times was unsuccessful. I tried to put this comment in response to an article by Ronald W. Pies, MD on anonymous posters that are abusive and in some cases threatening. He discusses situations where psychiatrists who are not anonymous are subjected to these tactics by anonymous posters. He goes on to say:
"It was therefore with great satisfaction that I learned of a new (6/27/12) policy on the popular medical Web site, Medscape; ie"we have removed the ability to post comments anonymously in our physician-only discussion forum, Medscape Connect, and in all Medscape blogs."
I am familiar with the discussion area on Medscape for quite a long time. There are anonymous posters there who are somewhat disagreeable. There are anonymous posters there who clearly have a lot of time on their hands. There are posters there whose main goal is to denigrate psychiatry and psychiatrists. Interestingly posts against psychiatrists and psychiatry have never been censored, no matter how off the wall they are. One psychiatrist fighting back, made several posts that were pulled. The abusive anonymous posters there usually fall back on "freedom of speech" as their right to say whatever they want about psychiatry. As far as I know only a psychiatrist was ever censored in that forum - but in that case an entire series of posts was pulled.
I have always advocated for physicians posting under their own name in any Internet discussion by physicians. When that does not happen there is always a predictable amount of rhetoric and name calling. At times the posts on Medscape were at such a level it was difficult to believe that they were made by physicians. Of all the specialty discussion boards on Medscape, it is probably no surprise that psychiatry was the only specialty under attack.
The problem currently is that despite their advertised policy, posting on Medscape's physician discussion forums really have not changed. I just looked at the forum and anonymous posting is alive and well. Bashing psychiatry is alive and well.
Old antipsychiatry habits die hard.
George Dawson, MD, DFAPA
Ronald W. Pies, MD. Is it time to stop anonymous (and abusive) posting on the Internet? Psychiatric Times; August 16, 2012.
"It was therefore with great satisfaction that I learned of a new (6/27/12) policy on the popular medical Web site, Medscape; ie"we have removed the ability to post comments anonymously in our physician-only discussion forum, Medscape Connect, and in all Medscape blogs."
I am familiar with the discussion area on Medscape for quite a long time. There are anonymous posters there who are somewhat disagreeable. There are anonymous posters there who clearly have a lot of time on their hands. There are posters there whose main goal is to denigrate psychiatry and psychiatrists. Interestingly posts against psychiatrists and psychiatry have never been censored, no matter how off the wall they are. One psychiatrist fighting back, made several posts that were pulled. The abusive anonymous posters there usually fall back on "freedom of speech" as their right to say whatever they want about psychiatry. As far as I know only a psychiatrist was ever censored in that forum - but in that case an entire series of posts was pulled.
I have always advocated for physicians posting under their own name in any Internet discussion by physicians. When that does not happen there is always a predictable amount of rhetoric and name calling. At times the posts on Medscape were at such a level it was difficult to believe that they were made by physicians. Of all the specialty discussion boards on Medscape, it is probably no surprise that psychiatry was the only specialty under attack.
The problem currently is that despite their advertised policy, posting on Medscape's physician discussion forums really have not changed. I just looked at the forum and anonymous posting is alive and well. Bashing psychiatry is alive and well.
Old antipsychiatry habits die hard.
George Dawson, MD, DFAPA
Ronald W. Pies, MD. Is it time to stop anonymous (and abusive) posting on the Internet? Psychiatric Times; August 16, 2012.
Why Are There No Detox Units Anymore?
Acute withdrawal from drugs and alcohol can kill you in
the worst case scenario and at best can prevent you from initiating the
recovery process. So why are there no
detox units anymore or at least very few of them? You can still end up in a hospital going
through detoxification or in a county facility where the priority is more
containment of the acutely intoxicated than appropriate medical detoxification. There are probably a handful of detoxification facilities where you will
see physicians with an interest or a specialty in addiction medicine using the
best possible standards. Why is the government and why are the managed care
systems that run healthcare in the United States not interested in
"evidence-based" medical detoxification?
As a person who has seen the system devolve and who has successfully
treated a lot of people who needed detoxification this is another deficiency
in the system of medical care that is never addressed. Over the course of my
career I have seen patients admitted to internal medicine services for detox in the
1980s. When insurance companies and managed care companies started to refuse
payment for that level of treatment intensity patients requiring detoxification
were then admitted to mental health units.
When mental health units started operating according to the managed care
paradigm of no treatment for people with severe addictions, they were either
sent home from the emergency department or sent to county detox facilities. Those county detox facilities were often low in quality and one incident away from being shut down.
I currently teach physicians about the management
of opioids and chronic pain in outpatient settings. I am impressed with the number of addicted
patients who are taking opioids for chronic pain. This population frequently has problems
with benzodiazepines. There is a general
awareness that we are in the midst of an opioid epidemic and in many counties
across the United States the death rate from accidental drug overdoses exceeds
the death rate from traffic fatalities. The question I get in my lecture is frequently
how to deal with the addicted pain patient who is clearly not getting any pain
relief from chronic opioid therapy and has often escalated the dosage to potentially
life-threatening amounts. In many chronic pain treatment algorithms this is the "discontinue opioids" branch point. During my most
recent lecture I posed the question to these physicians: “Do you have access to a
functional detoxification facility?" Not surprisingly - nobody did.
I can still recall the denial letters from managed care
companies when I was taking care of patients with alcoholism and addiction in
an inpatient setting. They had been admitted to my inpatient mental health unit
and many were also suicidal. The typical managed care comment was "this
patient should be detoxified in a detox unit and not admitted to a mental
health unit.” This is an example of the
brilliant concept called "medical necessity" as defined by a managed
care company. In the majority of these cases, the patient's county of residence
did not have a functional detox unit and there were also clear-cut reasons for
them to be on a mental health unit. County detox facilities do not take people with suicidal thinking or associated medical problems. I
wonder how many letters it took like the ones I received to permanently disrupt
the system so that patients with alcoholism and addictions could no longer get
standard medical care.
The end result has been no standards for medical
detoxification at all. Some patients are sent out of the emergency department
with a supply of benzodiazepines or opioids and advised to taper off of these
medications on their own. That advice ignores one of the central features of
substance abuse disorders and that is uncontrolled use. Without supervision I
would speculate that the majority of people who are sent home with medications to do their own detoxification take all that medication in the first day or two
and remain at risk for complications.
Appropriate detoxification facilities staffed by physicians
who are trained and interested in addictive disorders would go a long way toward
restoring quality medical care to people who have a life threatening addictions. It would restore more humanity to medicine - something that business decisions have removed. As far as I can tell, people struggling with addictions and alcoholism continue to be
neglected by both federal and state governments and the managed care industry.
George Dawson, MD, DFAPA
Sunday, September 2, 2012
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
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
Saturday, September 1, 2012
A Neurologist Gets High
Well known neurologist and author Oliver Sacks has written an essay in the New Yorker about his drug experiences in the 1960s. From about 1963-1967 Dr. Sacks ingested various compounds including cannabis, amphetamines, intravenous morphine, LSD, morning glory seeds, Artane (trihexyphenidyl hydrochloride) and massive doses of chloral hydrate with an accompanying withdrawal state. He does an excellent job of describing various intoxication and delirium states. As an example he describes his experience reading a text on migraines from 1873 while taking amphetamine:
"...In a sort of catatonic concentration that in 10 hours I scarcely moved a muscle or wet my lips, I read steadily through "Megrim"....At times I was unsure if I was reading the book or writing it...." p. 47
In my current professional iteration as an addiction psychiatrist these are familiar scenarios. At some level Sacks realizes that he is lucky to have survived chloral hydrate withdrawal induced delirium tremens and amphetamine-induced tachycardia up to the 200 beats per minute range with an unknown blood pressure. Vivid visual and auditory hallucinations and a distorted sense of time are described. There is also the familiar interpersonal dimension that gets activated when a person's life is affected by drug use - concerned colleagues that implore him to seek help and take care of himself.
Dr. Sacks is an intellectual and this is presented in an intellectual context that may not have been very evident at the time of the experimentation. He describes the sociocultural antecedents of a need for chemical transcendance that has been present throughout human history. He proceeds to describe some of the relevant historical writings of physicians and other intellectuals.
The usual debate about whether or not there is any utility in taking life threatening amounts of drugs occurs in the text and on the podcast. Not surprisingly, intellectuals derive insights from their experiences and taking drugs is no exception. In the article, the revolution in neurochemistry was one of the preludes to the period of experimentation. The problems with psychotic symptoms and manic states are well described as well as what states might be the preferred ones. We learn on the podcast that these experiences have provided insights into possible brain mechanisms and that this might be part of the basis for the author's new book Hallucinations that comes out in the fall.
Dr. Sacks describes himself as an observer and explorer of psychotic symptoms and how that seems to be protective when he is tripping. What is missing here compared to the people I have talked with is a highly subjective response that increases the risk for drug use. I typically hear about intense euphoria, high energy, and increased competence in physical, intellectual and social spheres. Not having that response may be protective and may allow one to avoid the risks of ongoing chemical use. In some cases there may just be a compulsion to recreate the drug induced state. The essay may have been a lot more complicated or written by someone else if those descriptions were there.
George Dawson, MD, DFAPA
Oliver Sacks. Altered States - Self experiments in chemistry. The New Yorker, August 27, 2012: 40-47.
Oliver Sacks. Podcast: The New Yorker Out Loud.
"...In a sort of catatonic concentration that in 10 hours I scarcely moved a muscle or wet my lips, I read steadily through "Megrim"....At times I was unsure if I was reading the book or writing it...." p. 47
In my current professional iteration as an addiction psychiatrist these are familiar scenarios. At some level Sacks realizes that he is lucky to have survived chloral hydrate withdrawal induced delirium tremens and amphetamine-induced tachycardia up to the 200 beats per minute range with an unknown blood pressure. Vivid visual and auditory hallucinations and a distorted sense of time are described. There is also the familiar interpersonal dimension that gets activated when a person's life is affected by drug use - concerned colleagues that implore him to seek help and take care of himself.
Dr. Sacks is an intellectual and this is presented in an intellectual context that may not have been very evident at the time of the experimentation. He describes the sociocultural antecedents of a need for chemical transcendance that has been present throughout human history. He proceeds to describe some of the relevant historical writings of physicians and other intellectuals.
The usual debate about whether or not there is any utility in taking life threatening amounts of drugs occurs in the text and on the podcast. Not surprisingly, intellectuals derive insights from their experiences and taking drugs is no exception. In the article, the revolution in neurochemistry was one of the preludes to the period of experimentation. The problems with psychotic symptoms and manic states are well described as well as what states might be the preferred ones. We learn on the podcast that these experiences have provided insights into possible brain mechanisms and that this might be part of the basis for the author's new book Hallucinations that comes out in the fall.
Dr. Sacks describes himself as an observer and explorer of psychotic symptoms and how that seems to be protective when he is tripping. What is missing here compared to the people I have talked with is a highly subjective response that increases the risk for drug use. I typically hear about intense euphoria, high energy, and increased competence in physical, intellectual and social spheres. Not having that response may be protective and may allow one to avoid the risks of ongoing chemical use. In some cases there may just be a compulsion to recreate the drug induced state. The essay may have been a lot more complicated or written by someone else if those descriptions were there.
George Dawson, MD, DFAPA
Oliver Sacks. Altered States - Self experiments in chemistry. The New Yorker, August 27, 2012: 40-47.
Oliver Sacks. Podcast: The New Yorker Out Loud.
Friday, August 24, 2012
Lance Armstrong and parallels with physician discipline
I read the headlines in the paper today "Armstrong stripped of seven Tour titles." I had just read his personal position on Facebook. For those who have not followed this issue, the US Anti Doping Agency (USADA) has been trying to say that Armstrong violated doping regulations by using banned substances despite a significant amount of objective evidence in his favor. The objective evidence in his favor was to such a degree that the Department of Justice dropped a 2 year investigation of him. The USADA is not a branch of law enforcement branch but it does have the power to ban athletes, ban them for life, and apparently remove any awards that they have won in a retrospective manner even though they were under intense scrutiny at the time. In my reading the USADA also apparently believes that their test results are infallible which makes their spin on those results even more confusing. As Armstrong points out - during competition he had to submit for testing 24/7 at at no time did the USADA say that he had a positive test result or pull him from competition. I am not going to review the pros and cons of the decision - only to say that at this point it has been politicized and a stunning amount of objective evidence has been ignored. My interest in the process is how it resembles similar processes that are conducted against physicians.
The "disruptive physician" concept seems to have been the driving force behind a lot of these initiatives. Disruptive physicians to me would be physicians who have not violated the medical practice statutes in their states. They would be basically physicians that somebody doesn't like because of their behavior or personality. The Joint Commission has a position statement:
The "disruptive physician" concept seems to have been the driving force behind a lot of these initiatives. Disruptive physicians to me would be physicians who have not violated the medical practice statutes in their states. They would be basically physicians that somebody doesn't like because of their behavior or personality. The Joint Commission has a position statement:
"Intimidating and disruptive
behaviors including overt actions such as verbal outbursts and physical
threats, as well as passive activities such as refusing to perform assigned
tasks were quietly exhibiting uncooperative attitudes during routine
activities. Intimidating and disruptive behaviors are often manifested by
healthcare professionals in positions of power. Such behaviors include
reluctance or refusal to answer questions, return phone calls or pages,
condescending language or voice intonation, and impatience with questions or it
overt and passive behaviors undermine team effectiveness and can compromise the
safety of patients. All intimidating and disruptive behaviors are
unprofessional and should not be tolerated."
They go on to cite research suggesting that these behaviors are widespread as high as 40% in some settings. The research is survey research and there are no concerns about its potential quality or biases. My concern and working in a number of medical settings for the past 30 years is that I have witnessed it exactly once. An attending physician personally verbally attacked me several times after he learned I was going to be a psychiatrist at least until I outguessed him on the correct diagnosis of acute abdominal pain. I think that behavior would clearly qualify.
On the other hand, I have become aware of many physicians being disciplined and even losing their jobs over trivial situations in the workplace. Apparently the threshold for a complaint against a physician is that the complainant feels as if they were "disrespected". In today's healthcare environment that complaint plus a personal dislike from a department chairman is enough to get you fired or at least live a miserable existence until you decide to quit. That is true irrespective of the number of people who would testify on your behalf, service to the department, patient satisfaction ratings, ratings by residents and medical students, and other professional accomplishments. If you are a physician these days all it takes is the subjective opinion from someone who does not know you or your personal motivation or reasons for doing things to file a complaint and potentially destroy your career. Even if you are not fired outright, there could be a lingering process of accumulating demerits and reviews by other physicians who are not sympathetic to your plight before you are ultimately let go.
At least Lance Armstrong can say that a ton of objective evidence was ignored in order to make this decision. The decision against a physician can be based on a single subjective complaint irrespective of how reliable or credible the complainant is and what sort of evidence exists.
That is all it takes to be a disruptive physician.
That is all it takes to be a disruptive physician.
George Dawson, MD. DFAPA
Monday, August 20, 2012
AMA, DOJ, and managed care all on the same side?
That's right and they are all potentially aligned against doctors.
The lesson from the 1990's and again in the early 20th century was that politicians who were not competent to address health care reform in any functional way could come up with all sorts of off-the-wall-theories. One of the most off-the-wall theories was that widespread health care fraud was a major cause of health care inflation. It stands to reason if that is the case that is true, the perpetrators would be easy to find and put out of business. To borrow typical language of the Executive branch it was a War on Healthcare Fraud.
To anyone who did not endure it, it is now a well kept secret. The tactics of the government used in those days - entering clinics and doctors offices in an intimidating manner and taking out boxes and boxes of charts for review by special agents who were "coding experts" and then assigning some tremendous fine based on alleged "fraud" have been expunged from most places. I sent two Freedom of Information Act requests to involved federal agencies and was told that information "did not exist" even after I provided the front page from one of the documents with the name of the agency.
It was quite a spectacle and it had doctors everywhere running scared. After all, the interpretation of notes and linking them to billing documents was entirely subjective. If a handful of notes was reviewed and bills were actually sent through the mail - racketeering charges via RICO statutes were possible and the fines would skyrocket to the point that nobody could ever pay them. Federal prison was a possibility. All for having a deficient note?
What followed was a carefully orchestrated set of maneuvers to render beleaguered physicians even weaker. A decade of millions and millions of hours wasted on worthless documentation out of paranoia of a government audit. Whose notes actually "fit" the government criteria? The notes varied drastically from clinic to clinic and year to year in the same clinic. And then a masterful stroke. The government probably realized that their micromanagement of progress notes as leverage against physician productivity was probably undoable. It would take far more agents than the budget would allow and they would no longer be able to demonstrate "cost effectiveness" in terms of recovered funds on the DOJ web site.
At that point they were able to turn this political device over to managed care companies who could selectively apply it anyway they wanted. Some physicians noted that their documentation and coding scores by internal audit could be the best in the organization one year and the worst then next even though they had not changed any of their paperwork practices. These audits to assure compliance with federal guidelines quickly became a mechanism for managed care organization (MCOs) to deny payment and "downcode" a practitioner's billing based on their review of chart notes. Incredibly the MCO could deny payment for a block of billing submitted or pay much less than what was submitted. Where else in our society can you decide to pay whatever you want for a service rendered? That is the kind of power that the government gives MCOs.
Enter the new "partnership" to deal with health care fraud. It is basically a coalition of the same players who have been using the health care fraud rhetoric for the past 20 years. The DOJ, FBI, HHS OIG, large insurance companies and managed care corporations. This quote says it all:
"The joint effort acknowledges the limitations of each health care insurer relying solely on its own data and fraud prevention techniques. After a 2010 summit, 21 private payers and government agencies discovered that they were victims of the same scams. As a result, the participants pledged to ban together against fraud."
The HHS Secretary chimed in:
"This partnership puts criminals on notice that we will find them and stop them before they steal health care dollars."
The newly elected psychiatrist-AMA president Jeremy Lazarus advises:
"Claims coding and documentation involve complicated clinical issues and the analysis of these claims requires the clinical lens of physician education and training."
Good luck with that Dr. Lazarus and heaven help any physician who gets caught under the managed care-federal government juggernaut. And who protects physicians against those who are defrauding them by non payment or trivial payment for services rendered based on a totally subjective interpretation of a chart note? Nobody I guess. I guess we will continue to deny that is possible and a common occurrence.
This can only happen in a country where the government provides businesses with every possible bit of leverage against physicians and where most political theories about health care reform are pure fantasy.
George Dawson, MD, DFAPA
Charles Feigl. New public-private partnership targets health fraud. AMNews August 20, 2012.
The lesson from the 1990's and again in the early 20th century was that politicians who were not competent to address health care reform in any functional way could come up with all sorts of off-the-wall-theories. One of the most off-the-wall theories was that widespread health care fraud was a major cause of health care inflation. It stands to reason if that is the case that is true, the perpetrators would be easy to find and put out of business. To borrow typical language of the Executive branch it was a War on Healthcare Fraud.
To anyone who did not endure it, it is now a well kept secret. The tactics of the government used in those days - entering clinics and doctors offices in an intimidating manner and taking out boxes and boxes of charts for review by special agents who were "coding experts" and then assigning some tremendous fine based on alleged "fraud" have been expunged from most places. I sent two Freedom of Information Act requests to involved federal agencies and was told that information "did not exist" even after I provided the front page from one of the documents with the name of the agency.
It was quite a spectacle and it had doctors everywhere running scared. After all, the interpretation of notes and linking them to billing documents was entirely subjective. If a handful of notes was reviewed and bills were actually sent through the mail - racketeering charges via RICO statutes were possible and the fines would skyrocket to the point that nobody could ever pay them. Federal prison was a possibility. All for having a deficient note?
What followed was a carefully orchestrated set of maneuvers to render beleaguered physicians even weaker. A decade of millions and millions of hours wasted on worthless documentation out of paranoia of a government audit. Whose notes actually "fit" the government criteria? The notes varied drastically from clinic to clinic and year to year in the same clinic. And then a masterful stroke. The government probably realized that their micromanagement of progress notes as leverage against physician productivity was probably undoable. It would take far more agents than the budget would allow and they would no longer be able to demonstrate "cost effectiveness" in terms of recovered funds on the DOJ web site.
At that point they were able to turn this political device over to managed care companies who could selectively apply it anyway they wanted. Some physicians noted that their documentation and coding scores by internal audit could be the best in the organization one year and the worst then next even though they had not changed any of their paperwork practices. These audits to assure compliance with federal guidelines quickly became a mechanism for managed care organization (MCOs) to deny payment and "downcode" a practitioner's billing based on their review of chart notes. Incredibly the MCO could deny payment for a block of billing submitted or pay much less than what was submitted. Where else in our society can you decide to pay whatever you want for a service rendered? That is the kind of power that the government gives MCOs.
Enter the new "partnership" to deal with health care fraud. It is basically a coalition of the same players who have been using the health care fraud rhetoric for the past 20 years. The DOJ, FBI, HHS OIG, large insurance companies and managed care corporations. This quote says it all:
"The joint effort acknowledges the limitations of each health care insurer relying solely on its own data and fraud prevention techniques. After a 2010 summit, 21 private payers and government agencies discovered that they were victims of the same scams. As a result, the participants pledged to ban together against fraud."
The HHS Secretary chimed in:
"This partnership puts criminals on notice that we will find them and stop them before they steal health care dollars."
The newly elected psychiatrist-AMA president Jeremy Lazarus advises:
"Claims coding and documentation involve complicated clinical issues and the analysis of these claims requires the clinical lens of physician education and training."
Good luck with that Dr. Lazarus and heaven help any physician who gets caught under the managed care-federal government juggernaut. And who protects physicians against those who are defrauding them by non payment or trivial payment for services rendered based on a totally subjective interpretation of a chart note? Nobody I guess. I guess we will continue to deny that is possible and a common occurrence.
This can only happen in a country where the government provides businesses with every possible bit of leverage against physicians and where most political theories about health care reform are pure fantasy.
George Dawson, MD, DFAPA
Charles Feigl. New public-private partnership targets health fraud. AMNews August 20, 2012.
Thursday, August 16, 2012
Violence Prevention - Is The Scientific Community Finally Getting It?
I have
been an advocate for violence prevention including mass homicides and mass
shootings for many years now. It has involved
swimming upstream against politicians and the public in general who seem to
believe that violence prevention is not possible. A large part of that attitude is secondary to
politics involved with the Second Amendment and a strong lobby from firearm advocates. My position has been that you can study the
problem scientifically and come up with solutions independent of the firearms
issue based on the experience of psychiatrists who routinely treat people who
are potentially violent and aggressive.
I was
very interested to see the editorial in this week's Nature advocating the scientific study of mass homicides and
firearm violence. They make the interesting observation that one media story
referred to one of the recent perpetrators as being supported by the United States
National Institutes of Health and somehow implicating that agency in the
shooting spree and that:
"In this climate,
discussions of the multiple murders sounded all too often like descriptions of
the random and inevitable carnage caused by a tornado or earthquake".
Even
more interesting is the fact that the National Rifle Association began a
successful campaign to squash any scientific efforts to study the problem in
1996 when it shut down a gun violence research effort by the Centers for
Disease Control and Prevention. The authors go on to list two New England
Journal of Medicine studies from that group that showed a 2.7 fold greater risk
of homicide in people living in homes where there was a firearm and a 4.8 fold
greater risk of suicide. Even worse:
"Congress
has included in annual spending laws the stipulation that none of the CDC's
injury prevention funds "may be used to advocate or promote gun
control"."
This
year the ban was extended to all agencies of the Department of Health and Human
Services including the NIH. There is
nothing like a gag order on science based on political ideology.
The
authors conclude by saying that rational decisions on firearms cannot occur in
a "scientific vacuum". That
is certainly accurate from both a psychiatric perspective and the firearms
licensing and registration perspective. Based on their responses to the most
recent incidents it should be clear that politicians are not thoughtful about
this problem and they certainly have no solutions. We are well past time to
study this problem scientifically and start to design approaches to make mass
shootings a problem of the past rather than a frequently recurring problem.
George
Dawson, MD, DFAPA
Who
calls the shots? Nature. 2012 Aug 9;488(7410):129. doi: 10.1038/488129a. PubMed
PMID: 22874927.
Saturday, August 11, 2012
DSM5 Dead on Arrival!
That's right. The latest sensational blast on the fate of that darling of the media the DSM5 is that it is dead on arrival. That recent proclamation is from the Neuroskeptic and it is based on the analysis of criticism of DSM5 criteria for Generalized Anxiety Disorder (GAD). OK - the original proclamation was "increasingly likely DOA". I confess that at this point I have not read the original article by Starcevic, Portman, and Beck but the Neuroskeptic provides significant excerpts and analysis.
The broad criticism is that the category has been expanded and is therefore less specific. The authors are concerned that this will lead to more inclusion and that will have "negative consequences." The main concern is the "overmedicalization" of the worried and the dilution of clinical trails. All this gnashing of the teeth leads me to wonder if anyone has actually read the Generalized Anxiety Disorder DSM5 criteria that is available on line. The proposed new criteria, the old DSM-IV criteria and the rationale for the changes are readily observed. The basic changes include a reduction on the time criteria for excessive worry from 6 months to three months, the elimination of criteria about not being able to control worry, and the elimination of 4/6 symptoms under criteria C (easy fatigue, difficulty concentrating, irritability and sleep disturbance). A new section on associated behaviors including avoidance behavior a well known feature of anxiety disorders is included. The remaining sections on impairment and differential diagnosis are about the same. The GAD-7 is included as a severity measure although I note that the Pfizer copyright is not included.
So what about all of the criticism? The "Rationale" tab is a good read on the DSM5 web site. I can say that clinically non-experts are generally clueless about the DSM-IV features of anxiety especially irritability. Most psychiatrists have a natural interest in irritability because we tend to see a lot of irritable people. There has been some isolated work on irritability but it really has not produced much probably because it is another nonspecific symptoms that cuts across multiple categories like the authors apply to cognitive problems and pain. So I will miss irritability but not much. Psychiatrists have to deal with it whether we have a category for it or not and hence the need for a diagnostic formulation in addition to a DSM diagnosis (managed care time constraints permitting).
But like most things psychiatric - the worried masses rarely present to psychiatrists for treatment these days. How likely is it that a busy primary care physician is going to review ANY DSM criteria for GAD? How likely is it that a person with a substance abuse disorder is going to disclose those details to a primary care physician as a probable cause of their anxiety disorder? How likely is it that benzodiazepines will be avoided as a first line treatment for any anxiety disorder? In my experience as an addiction psychiatrist I would place the probability in all three questions to be very low. It doesn't really matter if you use DSM-IV criteria or DSM5 criteria - the results are the same.
As far as "medicalization" goes, I am sure that somebody (probably on the Huffington Blog) will whip this into another rant about how the DSM5 enables psychiatrists to overdiagnose and overprescribe in our role as stooges for Big Pharma. But who really has an interest in treating all anxiety like a medical problem? I have previously posted John Greist's single handed efforts in promoting psychotherapy and computerized psychotherapy for anxiety disorders even to the point of saying that the results are superior to pharmacotherapy. In the meantime, what has the managed care cartel been doing? Although their published guidelines appear to be nonexistent it would be difficult to not see the parallels between approaches that use the PHQ-9 to assess and treat depression and using the parallel instrument GAD-7 in a similar manner. The problem with both approaches is that they are acontextual and the severity component cannot be adequately assessed. The goal of managed care approaches to treat depression is clearly to get as many people on medications as possible and call that adequate treatment. Why would the treatment of GAD be any different?
It should be obvious at this point that I am not too concerned about the DSM5, DSM-IV, or whatever diagnostic system somebody wants to use. The DSM5 is clearly about rearranging criteria based on recent studies with the sole exception of including valid biological markers for the sleep disorders section. Like many my speculation is that the ultimate information based approach to psychiatric disorders rests in genomics and refined epigenetic analysis and I look forward to that information being incorporated at some point along the way.
But let's get realistic about why the results of DSM technology are limited. As it is with DSM-IV and as it will be with DSM5, clinicians are free to interpret and diagnose basically whatever they want. Even with the vagaries of a DSM diagnosis, I doubt that the majority of primary care treatment hinges on a DSM diagnosis of any sort. I also doubt that the dominant managed care approach to diagnosis and treatment of GAD depends on a psychiatric diagnosis or research based treatment. It certainly excludes psychotherapy. Trying to pin those serious deficiencies as well as overexposure to medication on the DSM and psychiatrists is folly.
George Dawson, MD, DFAPA
1: Gorman JM. Generalized anxiety disorders. Mod Probl Pharmacopsychiatry. 1987; 22: 127-40. PubMed PMID: 3299062.
The broad criticism is that the category has been expanded and is therefore less specific. The authors are concerned that this will lead to more inclusion and that will have "negative consequences." The main concern is the "overmedicalization" of the worried and the dilution of clinical trails. All this gnashing of the teeth leads me to wonder if anyone has actually read the Generalized Anxiety Disorder DSM5 criteria that is available on line. The proposed new criteria, the old DSM-IV criteria and the rationale for the changes are readily observed. The basic changes include a reduction on the time criteria for excessive worry from 6 months to three months, the elimination of criteria about not being able to control worry, and the elimination of 4/6 symptoms under criteria C (easy fatigue, difficulty concentrating, irritability and sleep disturbance). A new section on associated behaviors including avoidance behavior a well known feature of anxiety disorders is included. The remaining sections on impairment and differential diagnosis are about the same. The GAD-7 is included as a severity measure although I note that the Pfizer copyright is not included.
So what about all of the criticism? The "Rationale" tab is a good read on the DSM5 web site. I can say that clinically non-experts are generally clueless about the DSM-IV features of anxiety especially irritability. Most psychiatrists have a natural interest in irritability because we tend to see a lot of irritable people. There has been some isolated work on irritability but it really has not produced much probably because it is another nonspecific symptoms that cuts across multiple categories like the authors apply to cognitive problems and pain. So I will miss irritability but not much. Psychiatrists have to deal with it whether we have a category for it or not and hence the need for a diagnostic formulation in addition to a DSM diagnosis (managed care time constraints permitting).
But like most things psychiatric - the worried masses rarely present to psychiatrists for treatment these days. How likely is it that a busy primary care physician is going to review ANY DSM criteria for GAD? How likely is it that a person with a substance abuse disorder is going to disclose those details to a primary care physician as a probable cause of their anxiety disorder? How likely is it that benzodiazepines will be avoided as a first line treatment for any anxiety disorder? In my experience as an addiction psychiatrist I would place the probability in all three questions to be very low. It doesn't really matter if you use DSM-IV criteria or DSM5 criteria - the results are the same.
As far as "medicalization" goes, I am sure that somebody (probably on the Huffington Blog) will whip this into another rant about how the DSM5 enables psychiatrists to overdiagnose and overprescribe in our role as stooges for Big Pharma. But who really has an interest in treating all anxiety like a medical problem? I have previously posted John Greist's single handed efforts in promoting psychotherapy and computerized psychotherapy for anxiety disorders even to the point of saying that the results are superior to pharmacotherapy. In the meantime, what has the managed care cartel been doing? Although their published guidelines appear to be nonexistent it would be difficult to not see the parallels between approaches that use the PHQ-9 to assess and treat depression and using the parallel instrument GAD-7 in a similar manner. The problem with both approaches is that they are acontextual and the severity component cannot be adequately assessed. The goal of managed care approaches to treat depression is clearly to get as many people on medications as possible and call that adequate treatment. Why would the treatment of GAD be any different?
It should be obvious at this point that I am not too concerned about the DSM5, DSM-IV, or whatever diagnostic system somebody wants to use. The DSM5 is clearly about rearranging criteria based on recent studies with the sole exception of including valid biological markers for the sleep disorders section. Like many my speculation is that the ultimate information based approach to psychiatric disorders rests in genomics and refined epigenetic analysis and I look forward to that information being incorporated at some point along the way.
But let's get realistic about why the results of DSM technology are limited. As it is with DSM-IV and as it will be with DSM5, clinicians are free to interpret and diagnose basically whatever they want. Even with the vagaries of a DSM diagnosis, I doubt that the majority of primary care treatment hinges on a DSM diagnosis of any sort. I also doubt that the dominant managed care approach to diagnosis and treatment of GAD depends on a psychiatric diagnosis or research based treatment. It certainly excludes psychotherapy. Trying to pin those serious deficiencies as well as overexposure to medication on the DSM and psychiatrists is folly.
George Dawson, MD, DFAPA
1: Gorman JM. Generalized anxiety disorders. Mod Probl Pharmacopsychiatry. 1987; 22: 127-40. PubMed PMID: 3299062.
Friday, August 10, 2012
Managed Care - A Variant of Looterism?
I follow several economic and financial blogs and I came across this piece on looterism yesterday. For those of you not interested in clicking on the blog post, looterism is defined as maximizing private benefit irrespective of a goal of creating value or "private benefit regardless of the damage." The author is focused on economic examples like banking corruption. If you actually follow the politics and corruption in our financial system there turn out to be endless examples. Dao references an earlier paper that nicely describes the current dynamic of maximizing extractable value rather than net economic worth so that the current creditors are left holding the bag.
I can't think of better example of looterism than managed care. Starting at the top end, what exactly occurs when a managed care company decides that they are not going to pay for an inpatient hospitalization for a patient with suicidal thinking. It gets more complicated in a hurry if that person has no housing, a history of actual suicide attempts, and a substance abuse problem. What happens if they say that they can be seen in an outpatient visit despite the fact that visit is two weeks away and it will involve a 15 minute conversation and a prescription that also may not be covered by the managed care company? I am a psychiatrist - so all of these denials are abhorrent to me, but what is the economic analysis of this situation?
The economic analysis is straightforward. The managed care company is not creating any value. Their product is supposed to be patient care and the situation as I described it is anything but patient care. Managed care advocates might say they are creating value by being better stewards of the resources. That is quite a stretch when they have essentially destroyed inpatient psychiatric care by promoting their mantra that a person needs to be "dangerous to oneself or others" in order to get admitted. Forget the notion that things are out of control at home and nobody has slept for a week. If the patient doesn't use the suicide word in the emergency department they are not getting in.
That completely artificial barrier to hospitalization has destroyed inpatient psychiatric care as a resource. People come in a crisis and many leave in the same crisis. There is no time for stabilization or a thoughtful analysis of the problem. Short crisis stays and inadequate reimbursement has a corrosive effect on staff morale, resources for the physical plant, and the quality of care delivered. Less and less value is created.
Eventually, staff with expertise can no longer tolerate the environment - especially when they are seeing more people and they are less able to help them given the managed care restraints. These staff leave and move to a more suitable patient care environment. The loss of knowledge workers creates even less value but it is a critical strategy in extracting value from mental health services and putting it somewhere else. If knowledge workers can't be demoralized managed care can always come up with a strategy to simply not pay them or pay them very little. The outpatient equivalent of inpatient care is seeing high volumes of outpatients - often for the sake of producing billing documents. The associated appointments are often low in value.
I would say that looterism is alive and well in the medical industry. You don't have to look very far in the health care economics field or your own health plan. The associated marketing campaigns that talk about high quality care associated with looterism should be cautiously approached. But that is a story for a different day.
George Dawson, MD, DFAPA
Francisco Dao. Looterism: The Cancerous Ethos That is Gutting America. August 7, 2012.
I can't think of better example of looterism than managed care. Starting at the top end, what exactly occurs when a managed care company decides that they are not going to pay for an inpatient hospitalization for a patient with suicidal thinking. It gets more complicated in a hurry if that person has no housing, a history of actual suicide attempts, and a substance abuse problem. What happens if they say that they can be seen in an outpatient visit despite the fact that visit is two weeks away and it will involve a 15 minute conversation and a prescription that also may not be covered by the managed care company? I am a psychiatrist - so all of these denials are abhorrent to me, but what is the economic analysis of this situation?
The economic analysis is straightforward. The managed care company is not creating any value. Their product is supposed to be patient care and the situation as I described it is anything but patient care. Managed care advocates might say they are creating value by being better stewards of the resources. That is quite a stretch when they have essentially destroyed inpatient psychiatric care by promoting their mantra that a person needs to be "dangerous to oneself or others" in order to get admitted. Forget the notion that things are out of control at home and nobody has slept for a week. If the patient doesn't use the suicide word in the emergency department they are not getting in.
That completely artificial barrier to hospitalization has destroyed inpatient psychiatric care as a resource. People come in a crisis and many leave in the same crisis. There is no time for stabilization or a thoughtful analysis of the problem. Short crisis stays and inadequate reimbursement has a corrosive effect on staff morale, resources for the physical plant, and the quality of care delivered. Less and less value is created.
Eventually, staff with expertise can no longer tolerate the environment - especially when they are seeing more people and they are less able to help them given the managed care restraints. These staff leave and move to a more suitable patient care environment. The loss of knowledge workers creates even less value but it is a critical strategy in extracting value from mental health services and putting it somewhere else. If knowledge workers can't be demoralized managed care can always come up with a strategy to simply not pay them or pay them very little. The outpatient equivalent of inpatient care is seeing high volumes of outpatients - often for the sake of producing billing documents. The associated appointments are often low in value.
I would say that looterism is alive and well in the medical industry. You don't have to look very far in the health care economics field or your own health plan. The associated marketing campaigns that talk about high quality care associated with looterism should be cautiously approached. But that is a story for a different day.
George Dawson, MD, DFAPA
Francisco Dao. Looterism: The Cancerous Ethos That is Gutting America. August 7, 2012.
Sunday, August 5, 2012
What does the Minnesota bill collecting scandal really mean?
The news this week in Minnesota was that the Attorney General had negotiated a settlement with Accretive Health Care over their collection techniques. When I read the original articles and summaries on the AG's web site, it reminded me of a conversation I had with a psychiatrist many years ago. He was hired by a hospital CEO who told him that he would be responsible for reminding patients that they needed to bring their insurance card for appointments. I thought that was an odd job for a physician but chalked it up to the generally poor level of administrative and clinical support that most psychiatrists get. One of his patients complained to the CEO about this process and he was fired. Another example of medical professionalism being compromised and then scapegoated by business practice.
I encourage anyone with more than a passing interest in just how far business practices have intruded and compromised medical practice to read the scenarios described in this Pioneer Press article. Patient after patient describing a situation where they were confronted bill collectors when they were either critically ill or just before surgery. The article also contain the industry's perspective:
"Point of service collections have become fairly standard practice." (page 6A, par 5)
The bottom line here is that this is really not quite the scandal that the Attorney General and the media are holding it up to be. The reason is very simple. Managed care is the dominant force in health care markets today. They hold that position because politicians in both state and federal governments want them to have that kind of power. As an example, Minnesota Statutes have managed care tactics written into them. These tactics have misplaced any professional input from physicians a long time ago. They use their own standards - many of which are made up within the industry and have no scientific backing. Business entities do not have any ethical standards. The ethics of a business are relative and depend a lot on the executives running it. It is clearly acceptable to confront you for a co-payment or past due bill even if you were too sick to think about picking up your wallet.
There is no reason to expect that these onerous collection practices will not be routine in the future. That should be obvious to anyone who can see that the influence of medicine and medical doctors is at an all time low. We frequently hear from politicians and bureaucrats that physician influence is never coming back and we should all: "Get used to it.". Hoping for a series of activist Attorney Generals is about all that's left.
If you are critically ill and somebody asks you for your charge card and looks irritated when you don't have it - you will have the managed care cartel and the government backing them to thank.
George Dawson, MD. DFAPA
Cristopher Snowbeck. Patients, hospital see lesson in billing furor. Pioneer Press. August 5, 2012.
I encourage anyone with more than a passing interest in just how far business practices have intruded and compromised medical practice to read the scenarios described in this Pioneer Press article. Patient after patient describing a situation where they were confronted bill collectors when they were either critically ill or just before surgery. The article also contain the industry's perspective:
"Point of service collections have become fairly standard practice." (page 6A, par 5)
The bottom line here is that this is really not quite the scandal that the Attorney General and the media are holding it up to be. The reason is very simple. Managed care is the dominant force in health care markets today. They hold that position because politicians in both state and federal governments want them to have that kind of power. As an example, Minnesota Statutes have managed care tactics written into them. These tactics have misplaced any professional input from physicians a long time ago. They use their own standards - many of which are made up within the industry and have no scientific backing. Business entities do not have any ethical standards. The ethics of a business are relative and depend a lot on the executives running it. It is clearly acceptable to confront you for a co-payment or past due bill even if you were too sick to think about picking up your wallet.
There is no reason to expect that these onerous collection practices will not be routine in the future. That should be obvious to anyone who can see that the influence of medicine and medical doctors is at an all time low. We frequently hear from politicians and bureaucrats that physician influence is never coming back and we should all: "Get used to it.". Hoping for a series of activist Attorney Generals is about all that's left.
If you are critically ill and somebody asks you for your charge card and looks irritated when you don't have it - you will have the managed care cartel and the government backing them to thank.
George Dawson, MD. DFAPA
Cristopher Snowbeck. Patients, hospital see lesson in billing furor. Pioneer Press. August 5, 2012.
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