The Birth of Managed Care

I recall a meeting of the private practice committee of the Manhattan District Branch of the American Psychiatric Association at the Payne-Whitney Clinic more than 25 years ago. I guess nobody was worried about the future of private practice back then. Only about three of us attended. We talked about psychiatrist Jay Reibel, MD at Four Winds psychiatric hospital and his attempts to cut costs for the State of New York by reviewing cases in what may have been the first "behavioral carve out."

We love to hate managed care in psychiatry as much as anywhere in medicine, but to help keep it all in perspective think back to the months long hospital stays and years of four sessions a week psychotherapy. Ask yourself whether we could ever be wealthy enough as a society to sustain such benefits for more than a privileged few. You can read more in this 1985 article from the New York Times:

http://www.nytimes.com/1985/12/01/nyregion/new-effort-seeks-to-insure-quality-of-psychiatric-care.html

Managed Care Bloopers

I had to read it several times to make sure my imagination had not taken over:

"All pregnant women should be on generic Subutex (buprenorphine)."

This bold statement appears fittingly in bold letters near the top of a Columbia United Providers Follow up Suboxone PA Form.

I think they meant to say something like, "Pregnant women taking buprenorphine should not be taking Suboxone, the preparation that also includes naloxone." So why did they not say what they meant? The gaffs continued:

Substance abuse program the patient is attending? ________________________

That was a question? I think not. How about,

Current dose of Suboxone for PA approval?

Again, not a question. When you (patient? physician? bus driver? It does not specify.) sign, you agree that:

I have read the CUP Policy on Suboxone Treatment and attest that all criteria and limiting conditions have been satisfied. [followed by boxes for Yes or No]

Do we really need those boxes? For more fun the Policy statement follows. See if you can guess what the writer meant by "criteria and limiting conditions":

TITLE: Columbia United Providers Suboxone Therapy Policy

Is it not kind of Columbia United Providers to let us know that what looks like a title really is in fact a title. I kid you not. "TITLE" really appears at the top. Now follow the criteria and limiting conditions (apparently):

Patients will NOT be able to purchase their own medication during or after treatment.

Makes me wonder how they (we?) can stop them. Does the statement refer to all medication? I suspect it just applies to buprenorphine preparations.

Patients will also be required to have a signed pain contract that includes random urine drug screens.

Apparently just any old pain contract will do, provided it is signed -- by somebody. The contract has to include a drug screen. Do you suppose they mean that the contract must obligate the patient to submit to drug screens? And here I thought we were talking about treating addiction, not pain.

I'm starting to feel like Andy Rooney here.

Providers will need to indicate the type of narcotic that was prescribed prior to Suboxone: and mg dose.

There we see a novel (and gratuitous) use of the colon, but yes, we providers will certainly need to indicate that, and hope that we do not have to figure out who "prescribed" the heroin. I have no idea what they mean by "type of narcotic." If you can guess, please comment.

No patient will be prescribed more pills/day than they actually take

The writer probably could not decide whether to end that with a question mark or a period. Maybe they just did not want to assume that it was in fact a sentence. Think about how to comply with this "limiting condition." In my experience prescribing has to take place before "taking," so compliance could be a challenge.

Patients that violate their contracts with providers will not have their prescriptions filled.

OK, but pharmacists fill prescriptions. How can the physician or the patient commit to what the pharmacist will do?

I hope this will help CUP rewrite their agreement and policy, and give you a few laughs. The intention here is to mock, make fun of, and otherwise ridicule bureaucrats, legislators, executives, and just about anyone else who reveals their ignorance or stupidity with respect to behavioral health care or any other aspect of medical care by gaffs, bloopers, grammatical blunders, and malapropisms. I solicit your contributions which will soon collect on a page attached to this blog.

If you're suicidal hang up and call the crisis line.

Despite the ubiquitous "If this is an emergency, hang up and dial 911" message I wonder how many patients who are sufficiently ambivalent about ending their lives to call their psychiatrist would call 911 instead. There seems to be an expectation (standard of care?) that psychiatrists can somehow talk them out of it over the phone, or attempt to stop the patient by involving 911 or other resources. I find it ironic that many argue that video conference (eg, Skype) is inadequate for even routine psychiatric encounters and yet expect psychiatrists to, on the spur of the moment, handle a life or death situation over the phone. Why not send these calls to the people who handle them all the time, crisis lines, and stop trying to be the hero like one of those movie psychiatrists? In Sybil Dr. Wilbur goes to her patient's apartment to rescue her. How far should one go to stop the patient from killing herself? Why stop with a telephone call?

Should we pretend to do something we cannot do? Does providing access outside of an appointment encourage or reward dysfunctional and potentially dangerous behavior?

"If you're suicidal, leave a message and you'll get a free telephone session with your physician who wants to be your hero and rescue you and provide you with attention and make you cared for, warm and fuzzy."

I am challenging an irrational myth which has become to some degree standard of care, at the very least an expectation, just because we perpetuate the illusion, a myth that interferes with providing appropriate after-hours assistance to patients. Does the fear of malpractice suits force us to do what may not be in the best interest of the patient, practicing what I call make-believe medicine?

As a physician I want to provide access by telephone after hours, but talking to me by phone is no substitute for going to an emergency room. I don't pretend to be capable of talking anyone out of any kind of bad behavior. Is there any evidence that any of us is capable of doing that? (other than in the movies)