Not Your Father's Travel Coverage

Only a few years ago covering for a colleague's practice while she traveled consisted almost entirely of taking the occasional crisis call, often to authorize a refill. Rarely you might meet with a patient in the office. Things have changed. I just returned from a ten day vacation. Thanks to the cloud I did not need anyone to cover for me, but a sampling of what came at me will give you some sense of some potential coverage duties.

Prior authorization has become an emergency, at least for patient and pharmacy, thanks to payers. Imagine trying to get authorization for a patient you have never met, especially without access to the medical record.

Record requests. Three of them came in by snail mail in the days before I left town. These can wait. But why should they? My records reside on a server somewhere in the cloud. I have no problem with my patients granting electronic view-only access to whomever they wish, whenever they wish. Alas my vendor does not seem to offer that capability. Yet.

Letter for a judge. A patient has run afoul of the law, and the attorney wants me to write a letter. This time it can wait, but I can envision a situation where delay could jeopardize the patient's defense. Regardless, I refuse to write letters if an opinion is requested, so we fall back on providing access to the medical record.

Nursing order. A patient taking clozapine needs regular blood draws, and the nursing service claims to urgently require my signature on the order form. Would you want to sign this if you were covering for me? Since I received it by electronic fax you probably would not know it had come in, but I suspect the nursing service would start frantic phone calls as the deadline approached. Seems like faxing the order form a few weeks early might help. Hint, hint.

Refills, other than controlled substances, rarely pose a problem. 

The one that really challenged me involved a recovering alcoholic who relapsed, no longer trusted oral naltrexone and desperately wanted a Vivitrol injection before leaving on an extended trip abroad. I met with the patient via video conference and agreed this plan made sense. I downloaded, signed, and faxed back the order, something a covering colleague could probably have handled (assuming room in the schedule). But then I received, while out of town, a confirmation letter, which indicated that Alkermes had shipped the drug to my office. But a representative assured me that the drug had been shipped to another office for injection and that the company just sends the same letter regardless. Any unemployed writers out there? This may seem like a minor discrepancy, but suppose the patient failed to get the injection after the physician relied on an erroneous form letter and drank again with some kind of terrible consequence. Please get that language right Alkermes.

The Positive in a Negative Online Review

Physicians, including psychiatrists, trying to cope with negative online reviews take heart. You can turn these lemons into lemonade. How many readers really trust them anyway? I often suspect that positive reviews may have been fabricated, and I have long believed that many negative reviews from real patients result when good doctors refuse, to the benefit of the patient, to prescribe bad drugs.

A recent negative review of my practice included accurate information about the way I run my practice. In many ways I do not like any more than does the patient that I must practice this way, but the broken system in which we work today requires me, for example, to collect payment at the time of service. I am glad the readers can learn about these problems from such reviews.

If the physician can identify the patient she may discover information that the patient has not shared directly but which may help in getting the best care for the patient. For example, if the patient clearly dislikes the physician the patient may benefit from discharge so he can find a physician he likes.

Some Web sites provide the physician an opportunity to respond as I did to the review mentioned above. I took advantage of the opportunity to describe my practice policies in a neutral tone. Avoid defensive responses and criticism, even implied, of the reviewer. You will just invite a counter attack. If the reviewer levels valid criticism use the opportunity to own up to your mistakes and lay out a plan to rectify them.

Even negative communication can better no communication.

Adderall Is For "A"

This New York Times article has already generated enormous controversy and not a little resentment from psychiatrists who seem to believe the Times is out to get them. The article would have us believe that the number of students using psychostimulant drugs like amphetamine and methylphenidate (Ritalin) has increased dramatically and that younger students than ever use the drugs to improve their performance on tests. I immediately connected the story to a recent listserv conversation among child psychiatrists touting the advantages of prescribing ever higher doses for presumed ADHD. How many of their patients actually take the higher doses rather than diverting to their friends, which of course could land them in jail? But perhaps more significantly, and more surprisingly to me, the article has generated numerous comments from physicians suggesting that anyone and everyone should have access to drugs that improve performance regardless of whether they suffer from a diagnosable condition.

Where will this take us? Some possible consequences:

• Patients and their parents will lose credibility with some physicians.
• Patients will drop reluctant physicians and seek out those more willing to write a prescription.
• Payers will demand more proof that subscribers really have the claimed condition.
• Schools and testing organizations will require pre-examination drug testing.
• Test takers will require proof of need from students who test positive for drugs.
• Increase in ADA complaints of discrimination if those who test positive for drugs are excluded from examinations.
• Independent psychiatric examinations costing thousands to prove appropriateness of prescriptions. (Never mind that no objective test for ADHD exists.)
• More will abuse or become dependent on the drugs.
• More will suffer adverse effects and overdoses.

How far should we go in allowing access to these drugs for performance enhancement? Why even involve physicians in deciding who gets them if a diagnosis is not required? How can we assure fairness in high stakes testing of students?

Silver Lining in Illinois

If you thought the process to revise the Diagnostic and Statistical Manual to produce  DSM-5 might short change science (what little exists) in favor of politics, imagine a gaggle of real politicians legislating diagnosis in the Illinois Senate. IL Senate Bill 679 appears to do just that to the apparent joy of Autism Action Network. As I read it the bill provides that anyone diagnosed with Autistic Disorder under DSM-4 TR will keep benefits they might have lost with adoption of more restrictive DSM-5 criteria.

You can call this a slap in the face to the American Psychiatric Association and DSM-5.

However, in effectively disconnecting benefits from DSM the IL Senate may have freed the authors of the diagnostic manual from external political pressures, allowing them more discretion to give priority to evidence and science rather than financial impact in crafting criteria and categories.

Now if only we could get out from under the AMA's CPT codes so physicians could charge by the hour or by whatever other paradigm we choose, and let the payers and their subscribers fight over reimbursement without trying to put physicians in the middle.