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.
Saturday, September 1, 2012
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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