I Do Solemnly Swear

In Maryland, there is a tiered formulary for Medicaid patients.  What this means is that the physician must try a first tier medication before a second tier medication.  What makes a medication a tier one medicine? The cost.  Some medicines are more expensive than others, and beside that, the state contracts with pharmaceutical companies for special rates.  So in Maryland, if you want to prescribe risperdone, it's not a problem.  If you want to prescribe some of the other atypical antipsychotic medications, you need to fill out a prior authorization form giving the diagnosis, the target symptoms, the name of the medicine, the dose, strength, frequency, and quantity.  The doc needs to check off whether it's being continued from an inpatient setting, if there is a condition or drug interaction which prevents use of a preferred (i.e., cheaper) medication, s/he must list other medications that have been tried with their strength, frequency, dates of use, "compliance (at least 6 days/wk)" and reason for discontinuation.  Oh and the demographics of all involved including the doc's NPI number, specialty, address, fax, email, phone, and the patient's name, DOB, address, Medicaid number and height and weight and gender.  Just a simple little form.

Finally, at the bottom of the form, the prescriber must sign off on the following statement, "I certify that the benefits of antipsychotic treatment for this patient outweigh the risks."  So like how does anyone know that before the patient even takes the pill?  Risk benefit is an individual issue and depends on  a balance of side effects and response to a medication.  Until the pill is swallowed (and perhaps until quite a few pills are swallowed), we don't know if the patient will have side effects, or if the patient's symptoms will even respond.  Mind you, if the patient doesn't respond to the initial dose and we to raise it, the doctor needs to fill the form out all over.  I think the state needs fortune tellers, not doctors. 

A Cry for Help

When Roy and I were on Talk of the Nation this past week, a called phoned in to ask about her sister. The question was about care in the Emergency Room/Department, so it was a perfect Roy question and he fielded it. I've been playing with it since, and wanted to talk more about this particular scenario, because the scenario was very common, and the question was more complicated than it seems.

From the transcript of the show:

ANN (Caller): Hi, thank you very much. I would like to ask Dr. Roy (oh, I gave him his blog name here) a question: My sister was admitted to emergency when she cut her wrists, and the doctor on call pulled me aside and said, do you think she was trying to kill herself?

And I said - because my sister is very intelligent - I said, if my sister really wanted to kill herself, she would have done it. I think she's asking for help.

And so he said - and so he had her see the healthy who was on call, or on duty. And she spoke with him for a while. And he sent her home, saying: Well, if you need me, I'm here.

What I would like to ask Dr. Roy is, what protocol was going on there? Why did they allow that to happen? And what would you change, if you could?

----
Roy did a great job touching on issues of voluntary versus involuntary hospitalization and the importance of hooking someone who is looking for help in to outpatient care.

If this were more of a two-way conversation, I'd want to ask more questions. What did the caller think should have happened? Was the sister given a referral for outpatient care? Was she asked if she wanted one? Was she already in treatment? My sense --and I could easily be wrong-- was that the caller thought the patient should be admitted to the hospital. She was desperate and ready now for help. The doctor asked the sister if she thought the patient wanted to commit suicide; hopefully the patient was asked that as well.

So if the caller thought her sister should have been hospitalized, there are things about the 'system' she isn't aware of. Hospital inpatient units are a place that people go to be kept safe. In many ways, they are a holding place and the goals there do not include treatment back to wellness, but treatment back to safety. It's a very low bar, and it ends up that only those who are imminently dangerous, or so disorganized as to be at risk, get admitted from an ER. There are some exceptions: if the ER doc doesn't believe a patient who says he's not suicidal/homicidal, he may err on the side of safety and admit the patient, or if the patient's behavior seems unpredictable, he may get admitted. At a community hospital, a typical length of stay is only a few days, very little actual psychotherapy occurs in the hospital, and while medications may be started, people are generally discharged before those medications can take effect or even be brought to steady-state levels. Gone are the days of long-term hospitalizations. And because of the acuity of illness in those people who are admitted to the hospital, psychiatric inpatient units are often not very restful places. If you want peace and quiet, you're better off in a hotel where you can order room service, have a massage, sleep peacefully, and it costs a whole lot less.

Sometimes people are admitted to specialty units where more intensive treatment does take place which may take longer and may have a goal that goes beyond imminent safety. There are special mood disorder units, eating disorder services, pain units, trauma disorder services, or inpatient stays for ECT...but one doesn't typically get admitted to these from the Emergency Room and often issues of payment limit who can be admitted and for how long. Of course, there is Clink's favorite place, The Retreat, where you can get help in a very pleasant environment, and I imagine they would be happy to have the sister of the caller from the radio, but that is self-pay.

"Getting help" usually means going to an outpatient therapist/healthy and it's not something that necessarily gets started while the moment is ripe. If there is a clinic associated with the hospital, they may have emergency slots for the ER to offer fast appointments, but other times, it can take many weeks to get a first appointment. Private practice varies a good deal-- I know shrinks who can get you in within the week, and others with a 6 week wait, and many who are simply too booked to take new patients.

I didn't write these rules, I'm just letting you know what they are. How do you think it should all work?

News Flash: Preauthorization Impacts Care

Thanks to Kery for heads up.
Illustration by J.C. Duffy / copyright © 2010 by the American College of Physicians

The American Medical Association had a press release on November 22nd and announced findings from their survey on the impact of insurance company preauthorization policies. Surprisingly, they discovered that these policies use physician time and delay treatment. It's funny, because preauthorization policies were designed to save money. And I imagine they do, for the insurer, but they cost money for everyone else.

I'm pasting the AMA findings here, taken directly from their website:
New AMA Survey Finds Insurer Preauthorization Policies Impact Patient Care

For immediate release:
Nov. 22, 2010

Chicago – Policies that require physicians to ask permission from a patient's insurance company before performing a treatment negatively impact patient care, according to a new survey released today by the American Medical Association (AMA). This is the first national physician survey by the AMA to quantify the burden of insurers' preauthorization requirements for a growing list of routine tests, procedures and drugs.

"Intrusive managed care oversight programs that substitute corporate policy for physicians' clinical judgment can delay patient access to medically necessary care," said AMA Immediate Past President J. James Rohack, M.D. "According to the AMA survey, 78 percent of physicians believe insurers use preauthorization requirements for an unreasonable list of tests, procedures and drugs."

The AMA survey of approximately 2,400 physicians indicates that health insurer requirements to preauthorize care has delayed or interrupted patient care, consumed significant amounts of time, and complicated medical decisions. Highlights from the AMA survey include:

• More than one-third (37%) of physicians experience a 20 percent rejection rate from insurers on first-time preauthorization requests for tests and procedures. More than half (57%) of physicians experience a 20 percent rejection rate from insurers on first-time preauthorization requests for drugs.

• Nearly half (46%) of physicians experience difficulty obtaining approval from insurers on 25 percent or more of preauthorization requests for tests and procedures. More than half (58%) of physicians experience difficulty obtaining approval from insurers on 25 percent or more of preauthorization requests for drugs.

• Nearly two-thirds (63%) of physicians typically wait several days to receive preauthorization from an insurer for tests and procedures, while one in eight (13%) wait more than a week. More than two-thirds (69%) of physicians typically wait several days to receive preauthorization from an insurer for drugs, while one in ten (10%) wait more than a week.

• Nearly two-thirds (64%) of physicians report it is difficult to determine which test and procedures require preauthorization by insurers. More than two-thirds (67%) of physicians report it is difficult to determine which drugs require preauthorization by insurers.

Preauthorization policies deliver costly bureaucratic hassles that take time from patient care. Physicians spend 20 hours per week on average just dealing with preauthorizations. Studies show that navigating the managed care maze costs physicians $23.2 to $31 billion a year.

"Nearly all physicians surveyed said that streamlining the preauthorization process is important and 75 percent believe an automated process would increase efficiency," said Dr. Rohack. "The AMA is urging health insurers to automate and streamline the current cumbersome preauthorization process so physicians can manage patient care more efficiently."