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.
Thursday, September 13, 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.
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