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Feds Should Respect State Legalization of Marijuana

As of today no Washington state law prohibits possession of less than an ounce of marijuana by an adult. Prosecutors in several jurisdictions have already dropped pending charges based on such possession. The state has started work on establishment of regulations to govern commerce in marijuana. Federal law, however, still prohibits associated activity.
The federal government should stop wasting lives and resources and let state law prevail where conflict exists. No good will come from a legal battle over states' rights or from continued enforcement of existing federal law in Washington or other states where adults can possess, grow, sell or use the substance (or hemp) legally.
Alcohol and nicotine should be classified as Schedule I drugs before marijuana, and none of these substances should require authorization or prescription by a medical professional.
Stop the real "reefer madness" now. Let us start dealing with marijuana problems with treatment instead of punishment.

Shame on this Jury

According to this article out of Syracuse, NY, a jury awarded $1,500,000 to the survivors (and their attorneys) after the suicide of teacher/coach Joe Mazella. The plaintiffs argued that Mazella's family doctor prescribed paroxetine for as long as 10 years and that he was negligent in doing so with little or no contact then abandoned the patient who killed himself without even telling his wife of his plan and after hospitalization and change in medication.

Anti-drug "reform" psychiatrist Peter Breggin wrote here about his testimony for the plaintiffs:

• The family doctor had increased the dose of paroxetine to 40 mg and added olanzapine after a telephone consultation.
• He criticized the family doctor for not warning Mazella about the "serious risks" associated with the drug (despite that fact that he had been taking the drug for 10 years!)
• "I also concluded that a hospital psychiatrist was negligent in not recognizing that Mr. Mazella was suffering from adverse drug effects and in discharging him without proper followup two weeks before his death."

In neither article could I find any basis for establishing a causal link to the suicide either with the admittedly negligent prescribing or the drugs themselves. Apparently Dr. Breggin finds it sufficient that one has taken such drugs prior to the suicide: post hoc ergo propter hoc.

Even the widow is quoted as saying, "He’d given no hint that he was suicidal, but he was complaining often about the effects of his medications, Janice Mazella said."

I might have testified for the defense:

• There is no evidence that any of the medications contributed to the suicide. Mazella's suicide resulted from his own wish to die, and nothing else. We will never know what motivated him to such a tragic choice.
• Nothing the family physician did or did not do contributed to the suicide. The hospital physicians assumed responsibility for his care after the family doctor discharged him. Even if this discharge somehow constituted abandonment his hospitalization obviated further need for involvement by the family physician. Mazella had apparently stopped the paroxetine prescribed by the family physician prior to killing himself. Perhaps he should have continued the drug.
• The hospital physicians could not assure that Mazella followed up at the appropriate interval with another physician after discharge. That was the responsibility of Mazella and the physician of his choice.
• If the drugs made Mazella feel so bad he should have stopped taking them on his own or at least sought consultation with another physician.
• For anyone to have stopped Mazella from killing himself required that they have contact with him during the time between his first thoughts of suicide but before the act, and that he tell them he intended to kill himself. Perhaps Dr. Breggin could have saved him had he been living with him 24/7!

According to the first article, "Janice Mazella said she hopes the verdict sends a message to patients and their loved ones to be careful about doctors overmedicating." It certainly does. It sends the message that if you kill yourself while taking the right medications, prescribed by a doctor with a good malpractice insurance policy, your survivors may be better off financially than they would have been had you remained alive.

Breggin calls Mazella's death the "tragic outcome" of use of prescribed antidepressant drugs. We may never know how many suicides occur among those who people like Breggin has frightened away from getting the treatment that could have saved them. But if your loved one kills herself after reading Breggin's propaganda and failing to get treatment, I want to be your expert witness.

Drug Screens and Insurance as Subsidy

Several months ago I started a quest for a new laboratory for oral fluid drug screens to conduct in my office, and got a lesson in medical economics in the bargain.

Oral fluid offers advantages over urine, particularly since we can observe collection with the patient in the waiting room. Also, since we mail the specimen to the laboratory for analysis, we do not have to worry about CLIA compliance.

I had hoped I could use Labcorp, which integrates with my electronic medical record, reporting results electronically, so I started with Labcorp. I connected with my representative there with some difficulty, but at first she evaded questions about pricing, assuring me that insurance would pay for the testing anyway. Eventually I discovered the analysis would cost more than $50, at least 4 times higher than what I had expected. The next few laps I contacted provided similar responses.

I had liked using the Quantisal collection device in the past, so I contacted them directly. They provided a list of laboratories using their technology, and I contacted each. Eventually I found several labs with much better pricing (under $10) and no run around. I chose J2 Laboratories whose service allows me to test for 6 drugs including buprenorphine, and I feel like my cash patients will get good value for their precious money.

Not that I like medical insurance companies, but with attitudes toward reimbursement examplified by Labcorp no wonder they push so hard to control costs. Let's hope Obamacare will bring improvements.

Earth to AMA: Substance Use Is Not Social

According to Wikipedia, the social history section of a medical history documented by a physician includes "living arrangements, occupation, marital status, number of children, drug use (including tobacco, alcohol, other recreational drug use), recent foreign travel, and exposure to environmental pathogens through recreational activities or pets."

In learning more about the Current Procedural Terminology published by the American Medical Association I was shocked to discover that even after decades of acceptance of addiction as a disease CPT still relegates this critical element of history to "social," a throwback to the days when physicians minimized use of tobacco, alcohol and other drugs by identifying it as a social activity.

Substance use deserves a heading of its own for documenting past, as well as current, drug use, including tobacco and alcohol, including sufficient data to establish presence or absence of a substance use disorder.

Prepare for the Coding Cliff

Meeting with a bunch of psychotherapists in my building the other day I asked how they planned to prepare for the changes in Current Procedural Terminology (CPT) codes scheduled to take effect on January 1. (CPT codes allow payers to reimburse for medical claims based on a numerical code.) None of them acknowledged any awareness of the change and its likely impact.

CPT codes have become one of the few remaining reasons for existence of the American Medical Association, which profits considerably from their publication, still a monopoly despite the fact that only a small minority of physicians still belong. Do not expect AMA to help you unless you belong. They make money selling the information you need.

I understand that new codes will replace all the old psychiatric codes, including initial evaluation, psychotherapy, and medical management. Do not expect payers to help you. If you submit an outdated code, they get to delay payment.

Psychotherapists may have it relatively easy. Just figure out what new codes replace the old codes.

Psychiatrists who provide what we used to call medical management will, however, start to use the same evaluation and management (E/M) codes internists and other primary care physicians have used for years. More complex than psychotherapy coding, each level of "procedure" requires performance of different services. For example, you may expect a sudden explosion in psychiatrists checking vital signs (pulse, blood pressure, etc.) at every encounter with patients who somehow survived all those past years without.

The devil may be in the documentation. Someday a payer may audit your records and have you sent to jail for fraud if your notes fail to support the procedure you claimed.

The American Psychiatric Association seems all excited at the prospect of psychiatrists obtaining reimbursement more commensurate with services provided. I will believe that when I see it. Do not expect APA to help unless you belong. APA retains few other benefits of membership. Notice I wrote reimbursement, not payment. This change means nothing to patients who pay you directly for your services. Do not expect them to jump for joy at the prospect of paying you more for the same service so your insured patients get better reimbursement. Ask them how much they want to pay for you to check blood pressure on every visit. Will we risk breaking some law if we continue to bill cash patients the old fashioned way while claiming new codes for those insured? Possibly.

How to prepare: I plan to look for online courses, ask my internist friends, and borrow a copy of one of the coding manuals published by AMA from a library. Good luck. Stay out of jail: only code for what you actually did.

Not Your Doctor's Medical Record?

As I prepare to shred box after box of patient files, all those more than ten years old, I contemplate the implications of now using an electronic medical record (EMR) "in the cloud." I wrote here about the impact of EMR on my deposition as a fact witness, but the more I think about it, the more additional potential I see for change.

Consider, for example, medical record law, both statutes like HIPAA and case law. Almost all of that body of law seems to evolve from the fact that until now the professional actually possessed the physical embodiment of the record. So it made sense to ask the professional to produce the record, to keep it secure, perhaps to copy it or allow the patient or a third party to copy it. And now it makes sense for me to destroy the older paper records in my possession.

I no longer possess those records that reside in the cloud as a jumble of bits and bytes on hard drives connected to servers located in one or more locations quite distant from my office. Now I have only the ability to access those records.

If I die or become disabled someone will have to provide for storage of, and control access to, my remaining paper records, but the bulk of active clinical information can remain in the cloud indefinitely. Third parties like my malpractice insurer and the patients themselves will retain an interest in preserving their access to the records. They have no need of me or my agents to control access. Nor should I or my estate have to pay for retention or copying (which with EMR means digital copying).

I believe patients should have full access to their medical records from the beginning, along with the ability to record change requests and disagreements. This access should persist after I have closed shop. The EMR vendor can easily allow read only access to my records while allowing the patient to add to the record as they see fit. But along with rights goes responsibility. The physician should assume no responsibility for any consequence of the patient accessing the record. Furthermore, the malpractice insurer and the courts should have unfettered read only access as well (with the usual safegards), as well as power to veto the patient's request to destroy it.

Cloud based records also promise to remove the physician from the often uncomfortable position of gatekeeper for third parties while the case remains active. With permission from the subscriber payers should  access the record directly to determine whether to authorize reimbursement for drugs, other treatments, and diagnostic procedures, rather than wasting the physician's time with telephone calls and forms. A patient applying for life insurance could likewise authorize access for review by the company. Patients involved in litigation like marital dissolution (divorce), contested custody, personal injury, criminal prosecution and other kinds of cases could authorize direct access by their attorneys and expert witnesses.

Direct access to cloud based records can ease administration of worker's compensation claims. Instead of wading through stacks of paper, independent examiners can access the electronic record directly.

Cloud based EMR as currently implemented offers access from almost anywhere, but the real potential may lie in the ability to offer -- or not -- access to almost any one, indefinitely.