Enough is enough! Stop the me-too drug explosion now.
Ask your doctor.
Did Danny Carlat write this song?
Gotta get me some of this.
Saturday, June 18, 2011
Do med schools select for wimps?
I have this pet theory that part of the reason medicine is in such a pathetic state today is the failure of docs to stand up for themselves and their patients. On the wimp spectrum I see psychiatrists at one end and surgeons at the other. To get into medical school you have to comply, comply, comply. Conform. Don't assert. Rebels and mavericks need not apply.
Thursday, June 16, 2011
What If Psychotherapy Required Physician Referral?
I didn't think much of it when my own physician wrote me some kind of order or prescription for 12 sessions of physical therapy a couple months ago, maybe just whether my medical insurance would claims for additional sessions differently. But a few days ago I was surprised to read in a physician forum a discussion of possible ramifications if physical therapists were allowed to treat patients directly, that is without referral from a physician. I had always assumed that patients could self refer to physical therapists in much the same way they can to psychotherapists.
This led me to wonder what it would be like if one could only engage the services of a psychotherapist with an order from the physician, maybe not necessarily even a psychiatrist. Maybe this would only apply to reimbursement. In other words you could self refer at will provided you paid cash, but perhaps there would be reimbursement from healthcare payers only with physician referral. Maybe it already works this way for some carriers.
How would this impact a typical psychotherapy practice? How would physicians determine whether to refer for psychotherapy? Would they get to know better the psychotherapists to whom they referred? It already seems to me that even psychiatrists might find it difficult to find a local psychotherapist who provides the type of psychotherapy best suited to a patient's particular problem. I suspect most physicians lump it all together as psychotherapy or counseling and don't know the difference between psychoanalysis and dialectical behavior therapy or between family system psychotherapy and primal scream. Certainly it would seem that physicians might be inundated with marketing efforts by psychotherapists clamoring for referrals. Maybe physicians would thus learn something about psychotherapy methods. Or would busy physicians just ignore it all and blindly authorize whatever treatment they are patients requested?
Under such a system might there be more communication, real collaboration, between physician and psychotherapist? Would it be easier or more difficult for patients to get treatment? What would be the impact on health care costs overall? Would such a policy solve problems or just create new ones?
This led me to wonder what it would be like if one could only engage the services of a psychotherapist with an order from the physician, maybe not necessarily even a psychiatrist. Maybe this would only apply to reimbursement. In other words you could self refer at will provided you paid cash, but perhaps there would be reimbursement from healthcare payers only with physician referral. Maybe it already works this way for some carriers.
How would this impact a typical psychotherapy practice? How would physicians determine whether to refer for psychotherapy? Would they get to know better the psychotherapists to whom they referred? It already seems to me that even psychiatrists might find it difficult to find a local psychotherapist who provides the type of psychotherapy best suited to a patient's particular problem. I suspect most physicians lump it all together as psychotherapy or counseling and don't know the difference between psychoanalysis and dialectical behavior therapy or between family system psychotherapy and primal scream. Certainly it would seem that physicians might be inundated with marketing efforts by psychotherapists clamoring for referrals. Maybe physicians would thus learn something about psychotherapy methods. Or would busy physicians just ignore it all and blindly authorize whatever treatment they are patients requested?
Under such a system might there be more communication, real collaboration, between physician and psychotherapist? Would it be easier or more difficult for patients to get treatment? What would be the impact on health care costs overall? Would such a policy solve problems or just create new ones?
Thursday, June 9, 2011
Apps for Psychiatry
Robert Post, MD started publishing paper charts for tracking mood, meds, events and other information relevant to Bipolar Disorder years ago, but Optimism here is the first I have discovered that might handle the task digitally. I hope they come up with an Android app.
I have not tried Optimism or recommended it to patients yet, but I have started tracking my own moods with the T2 Mood Tracker from the National Center for Telehealth and Technology. I find the free Android app easy to use. It produces a graph to track mood, anxiety, PTSD, and head injury related parameters. A patient could show it to his provider during visits, but I would like the capability for providers to view the chart in real time with a browser which would allow more accurate viewing via Skype/Tango. When the app detects out of the ordinary entries, it suggests you make a note, which you can also save in the app for later viewing.
A patient actually introduced me to the idea of an (iPhone) app for monitoring sleep. I downloaded the free Android app Sleep Graph. To use it I must activate it, then leave it on the corner of my bed all night. (I wonder whether it can produce separate graphs for each person and animal on the bed.)
Two apps from Apple appear to allow you to address sleep problems:
ResMed appears to focus on breathing related sleep problems.
Sleep Hygiene seems to record total sleep time and other parameters for overall sleep monitoring.
What other apps have you found useful for addressing psychiatric problems?
I have not tried Optimism or recommended it to patients yet, but I have started tracking my own moods with the T2 Mood Tracker from the National Center for Telehealth and Technology. I find the free Android app easy to use. It produces a graph to track mood, anxiety, PTSD, and head injury related parameters. A patient could show it to his provider during visits, but I would like the capability for providers to view the chart in real time with a browser which would allow more accurate viewing via Skype/Tango. When the app detects out of the ordinary entries, it suggests you make a note, which you can also save in the app for later viewing.
A patient actually introduced me to the idea of an (iPhone) app for monitoring sleep. I downloaded the free Android app Sleep Graph. To use it I must activate it, then leave it on the corner of my bed all night. (I wonder whether it can produce separate graphs for each person and animal on the bed.)
Two apps from Apple appear to allow you to address sleep problems:
ResMed appears to focus on breathing related sleep problems.
Sleep Hygiene seems to record total sleep time and other parameters for overall sleep monitoring.
What other apps have you found useful for addressing psychiatric problems?
Monday, May 30, 2011
Web Therapy
If you thought the 15 minute med check was bad, wait'l you see Fiona Wallice (Lisa Kudrow) conducting 3 minute Web therapy sessions:
Thursday, May 26, 2011
Upcoding for Cash
Well Mr. Jones, that's the end of today's visit. That will be $95. Wait a minute. I asked you about that cough. That counts as a partial review of systems, so I can tack on another $7.50. I also checked your med regimen for interactions. That gets me $9.99. And I did establish that you know who I am, where you are, and the time and date. Partial mental status exam counts for $12.75.
You probably cannot imagine doing that to a patient who pays cash for psychiatric treatment, but that is exactly what happens after many physicians and other providers wrap up a patient encounter when a third party payer foots the bill. If the physician fails to squeeze the maximum blood out of the reimbursement turnip in a hospital or a large enough group practice, a coding specialist will jump in.
Don't get me wrong. I dislike Medicare and private insurance companies as much as anyone, but there is something particularly disengenuous about sticking it to them when we would never approach a patient with the idea of attempting to squeeze every penny we can out of them. Quite the contrary, I tend to look for ways to charge my patients less for more. For example, I could have increased my fees to cover all the phone tag with patients and pharmacies, mostly related to refills and cancelling or rescheduling appointments. But a few months ago a patient had the audacity to text me, I texted her back, and now I save countless minutes over lower tech communication by texting with patients, easily enough to allow me to defer a fee increase for a few more months.
It's fine for physicians to make sure someone pays them adequately, especially when financial incentives lead to improved care, but when you stick it to the payer, whether it's a big guy like Medicare or a little guy like your patient, you ultimately stick it to all of us who pay premiums.
You probably cannot imagine doing that to a patient who pays cash for psychiatric treatment, but that is exactly what happens after many physicians and other providers wrap up a patient encounter when a third party payer foots the bill. If the physician fails to squeeze the maximum blood out of the reimbursement turnip in a hospital or a large enough group practice, a coding specialist will jump in.
Don't get me wrong. I dislike Medicare and private insurance companies as much as anyone, but there is something particularly disengenuous about sticking it to them when we would never approach a patient with the idea of attempting to squeeze every penny we can out of them. Quite the contrary, I tend to look for ways to charge my patients less for more. For example, I could have increased my fees to cover all the phone tag with patients and pharmacies, mostly related to refills and cancelling or rescheduling appointments. But a few months ago a patient had the audacity to text me, I texted her back, and now I save countless minutes over lower tech communication by texting with patients, easily enough to allow me to defer a fee increase for a few more months.
It's fine for physicians to make sure someone pays them adequately, especially when financial incentives lead to improved care, but when you stick it to the payer, whether it's a big guy like Medicare or a little guy like your patient, you ultimately stick it to all of us who pay premiums.
Thursday, May 19, 2011
Patient Falsely Claims to Not Have Medicare. Doctor Goes to Jail.
Sounds absurd, doesn't it? And of course it really hasn't happened. Yet. As far as I know.
But it could happen in your lifetime. Here's how:
Patients regularly call my office asking whether I "accept Medicare." Until about a month ago we politely explained that I opted out of Medicare. This means the patient must agree in writing that neither of us will ever bill Medicare for services I provide and that the fee I charge is between me and the patient. We are not bound by the Medicare fee schedule. About a month ago, however, I decide to stop treating patients who are covered by Medicare altogether. (Why is another story.)
Many of the patients who call my office, when we tell them I do not accept Medicare, tell us they cannot find a psychiatrist in the area who does accept Medicare. The obvious solution? Lie. After all, what physician or office staff would suspect someone of claiming NOT to have coverage? What might we say? Prove it. I suspect not. And besides how could the patient prove he does not have Medicare coverage?
Why would a physician want to make sure the patient is not covered by Medicare? There may be stiff civil or even criminal penalties for failing to file a claim with Medicare unless the physician has opted out. So adopting a "Don't ask. Don't tell." approach involves considerable risk.
How would the patient know the physician does not accept Medicare patients, and thus must lie? My practice Web site front page clearly states that I do not accept patients who have Medicare.
I contacted the Office of Communications/Media Relations Group at Centers for Medicare & Medicaid Services and inquired whether any such cases have been prosecuted. Ellen B. Griffith, Public Affairs Specialist, responded:
"As to whether a physician would be prosecuted for failing to submit a claim for services to a beneficiary who lied about his status – CMS is not an enforcement agency. Prosecutions of violations of Medicare law are handled either by the Office of Inspector General or the Department of Justice. I would suggest you contact them directly."
I then asked, "Is there a way a physician can confirm that a prospective patient is not a beneficiary by accessing a database at CMS or other agency?" So far no response.
I admit this hypothetical situation seems unlikely, but its very plausibility suggests Medicare badly needs fixing, and soon. You can join the conversation with seniors at AARP.
But it could happen in your lifetime. Here's how:
Patients regularly call my office asking whether I "accept Medicare." Until about a month ago we politely explained that I opted out of Medicare. This means the patient must agree in writing that neither of us will ever bill Medicare for services I provide and that the fee I charge is between me and the patient. We are not bound by the Medicare fee schedule. About a month ago, however, I decide to stop treating patients who are covered by Medicare altogether. (Why is another story.)
Many of the patients who call my office, when we tell them I do not accept Medicare, tell us they cannot find a psychiatrist in the area who does accept Medicare. The obvious solution? Lie. After all, what physician or office staff would suspect someone of claiming NOT to have coverage? What might we say? Prove it. I suspect not. And besides how could the patient prove he does not have Medicare coverage?
Why would a physician want to make sure the patient is not covered by Medicare? There may be stiff civil or even criminal penalties for failing to file a claim with Medicare unless the physician has opted out. So adopting a "Don't ask. Don't tell." approach involves considerable risk.
How would the patient know the physician does not accept Medicare patients, and thus must lie? My practice Web site front page clearly states that I do not accept patients who have Medicare.
I contacted the Office of Communications/Media Relations Group at Centers for Medicare & Medicaid Services and inquired whether any such cases have been prosecuted. Ellen B. Griffith, Public Affairs Specialist, responded:
"As to whether a physician would be prosecuted for failing to submit a claim for services to a beneficiary who lied about his status – CMS is not an enforcement agency. Prosecutions of violations of Medicare law are handled either by the Office of Inspector General or the Department of Justice. I would suggest you contact them directly."
I then asked, "Is there a way a physician can confirm that a prospective patient is not a beneficiary by accessing a database at CMS or other agency?" So far no response.
I admit this hypothetical situation seems unlikely, but its very plausibility suggests Medicare badly needs fixing, and soon. You can join the conversation with seniors at AARP.
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