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. 

Running Out of Psychiatric Beds

I read today that Eastern Ontario has started a bed registry to keep track of where open psychiatric beds are available. This is something I've long advocated. The United States now has less than 10% of the beds it used to have 50 years ago. Granted, treatment has improved and community resources are enhanced. But there are still areas that often do not have a sufficient number of hospital beds for folks needing acute inpatient psychiatric care.

The Ontario story described in the Ottawa Citizen states that six of the area hospitals have been connected to a computerized "bed board" that provides real-time information on who has an appropriate bed available. This saves time in the ER and gets patients to needed treatment more quickly. Otherwise, calls need to be made to each individual hospital, which is very time-consuming.

And it is not uncommon for all the beds to be full. Last July there was an EMTALA complaint against a hospital in Maryland because a patient sat in the ER all weekend, and this hospital said they had no beds to admit the patient to. The Department of Health and Mental Hygiene investigated the complaint and found that, indeed, the hospital was full that weekend. The ER's record indicated that all the hospitals (except the state hospitals) were called that weekend and all indicated their beds were full. So, DHMH visited every hospital (about 28, I think) thinking that surely one of them had an empty bed they were hiding. What they discovered was that every single psychiatric bed in the state was full.

Unfortunately, we have no way of determining how often this happens, but we know if happens often enough. A "bed board" like this would be very helpful in (1) quickly finding beds when needed, and (2) keeping track of the extent of this problem. Having patients wait in ERs for days is unsafe and is even discriminatory. How many people with stroke or uncontrolled diabetes sit in ERs for days waiting to find a bed for treatment? I'd like to hear others' thoughts on how this problem can be addressed.

[Note: my apologies to our readers for not blogging or commenting much over the last year or so. I plan to be more engaged again in Shrink Rap going forwards. I'll never talk as much as Dinah does, but I'll get some words in :-]