To get ideas for a new logo for BehaveNet I viewed a dozen or so Web sites related to behavioral health care, mostly a variety of providers running the spectrum from psychotherapists of all kinds to drug rehab residential facilities.You can probably guess what I found: birds and butterflies, flowers and trees, waves and water, brains and molecules, happy, fulfilled appearing people, some with their arms in the air, and a variety of abstract shapes. You can probably imagine the marketing people pushing positive images depicting happiness and light, growth and fulfillment. Avoid reference to pain and suffering, failure and defeat. Avoid reference to reality. Talk about issues instead of symptoms and dysfunction.
I wonder to what extent this approach to marketing reflects the fact that most of us prefer to work with low risk patients, the worried well. And who could blame us? We want to help, but who wants to (or can afford to) accept responsibility for the too numerous horrible outcomes? Certainly not our society, always looking to blame the professional when someone who may suffer from a mental illness does something shocking.
To survive we may strive to shun the people who need our help most, even if only by the subtle means of attracting cases that allow us to sleep at night.
I hope the disclaimers will suffice to keep the judges and juries from holding BehaveNet responsible for bad outcomes. So when I started the logo design process I said no birds or butterflies, no smiling faces or flowers, and I mentioned Mr. Loughner. We pursue serious professions, and the serious problems exist. I welcome suggestions.
Thursday, September 8, 2011
Thursday, August 25, 2011
Contingency Fee for Physicians
"We've already established what you are, ma'am. Now we're just haggling over the price." - George Bernard Shaw
The debate rages: Should physicians charge a fee for non-clinical tasks such as completing FMLA and disability forms, utilization (peer) review, and prior authorization for reimbursement for drugs, tests and procedures? As physician reimbursement plummets physicians increasingly wonder how they will pay the overhead, much less take home enough to pay off the student loans and still make a living. Many physicians now charge a nominal fee, maybe $50, or an hourly rate which barely covers the loss of time entailed.
Keep in mind that in many cases a third party like a disability carrier or pharmacy benefit manager exploits the physician's wish to help the patient in order to obtain free service from the doc. Physicians rarely obtain payment from the third party, and billing the third party raises ethical and role questions. The physician should work for the patient, but the third party foots the bill. Who does the physician work for anyway? And yes, the same question arises when the physician accepts money from insurers for rendering ordinary medical care, especially under contract.
Plaintiff's attorneys can collect as much as 30% or more of damage awards as contingency fees when they win a case. Not only does this practice assure an income, it also provides an incentive for them to take a case and spend their own money on trial expenses, like hiring expert witnesses, that many of their clients cannot afford.
Why don't physicians do the same? Let's say a patient applies for disability, and the policy allows for $1000 per month. If the physician completes the application, but the carrier rejects the claim, no one pays the physician either. But if the policy is awarded, the physician takes 30%, or $300 per month. It could work the same way for prior authorization for an expensive new atypical anti-psychotic. The physician would take 30% of the retail price as a reward for having obtained reimbursement.
This could change the game, giving physicians an incentive to increase skill at obtaining reimbursement. Experts with proven track records would sponsor courses. Physicians would publish their success rates on their Web sites. Patients would choose physicians, not by bedside manner or quality of medical care, but instead by how well they perform to obtain reimbursement.
What? You say there may be an ethical problem with this approach?
"We've already established what you are, ma'am. Now we're just haggling over the price." - George Bernard Shaw
The debate rages: Should physicians charge a fee for non-clinical tasks such as completing FMLA and disability forms, utilization (peer) review, and prior authorization for reimbursement for drugs, tests and procedures? As physician reimbursement plummets physicians increasingly wonder how they will pay the overhead, much less take home enough to pay off the student loans and still make a living. Many physicians now charge a nominal fee, maybe $50, or an hourly rate which barely covers the loss of time entailed.
Keep in mind that in many cases a third party like a disability carrier or pharmacy benefit manager exploits the physician's wish to help the patient in order to obtain free service from the doc. Physicians rarely obtain payment from the third party, and billing the third party raises ethical and role questions. The physician should work for the patient, but the third party foots the bill. Who does the physician work for anyway? And yes, the same question arises when the physician accepts money from insurers for rendering ordinary medical care, especially under contract.
Plaintiff's attorneys can collect as much as 30% or more of damage awards as contingency fees when they win a case. Not only does this practice assure an income, it also provides an incentive for them to take a case and spend their own money on trial expenses, like hiring expert witnesses, that many of their clients cannot afford.
Why don't physicians do the same? Let's say a patient applies for disability, and the policy allows for $1000 per month. If the physician completes the application, but the carrier rejects the claim, no one pays the physician either. But if the policy is awarded, the physician takes 30%, or $300 per month. It could work the same way for prior authorization for an expensive new atypical anti-psychotic. The physician would take 30% of the retail price as a reward for having obtained reimbursement.
This could change the game, giving physicians an incentive to increase skill at obtaining reimbursement. Experts with proven track records would sponsor courses. Physicians would publish their success rates on their Web sites. Patients would choose physicians, not by bedside manner or quality of medical care, but instead by how well they perform to obtain reimbursement.
What? You say there may be an ethical problem with this approach?
"We've already established what you are, ma'am. Now we're just haggling over the price." - George Bernard Shaw
Thursday, August 18, 2011
Voir Dire and HIPAA
Yesterday I presented myself for jury duty for the first time. It did not surprise me that the attorneys for a personal injury case rejected me after subjecting all the candidates to the process known as voir dire. The other prospective jurors, however, did surprise me by their willingness to discuss their medical histories openly in court. Not one refused to answer questions about injuries and treatment.
Truth be told, during the voir dire we identified ourselves only with large numbered placards, but the jury attendants had previously assigned numbers with names announced to as many as 100 prospective jurors, and selected jurors would likely introduce themselves during deliberation. I planned to refuse to provide what in any other venue would qualify as protected health information (PHI) under HIPAA, but neither judge nor attorney ever asked. I admitted only that I have never sustained an injury in a motor vehicle accident.
I still wonder whether the court can compel a prospective juror to reveal medical information. If so this would seem to represent a double standard of sorts and would seem to conflict with or even invalidate medical privacy safeguards.
All prospective jurors also dutifully stood, raised their right hands, and said, "I do," when ordered to swear the oath. (No one seemed to notice that I did not raise my hand or say, "I do.") In that situation most seem to accord great authority to judges, sometimes assuming judges possess authority they may not really have. I doubt that a judge can compel me to swear an oath. If this is true, and if judges lack the authority to compel release of medical information, they should inform prospective jurors of this fact.
Truth be told, during the voir dire we identified ourselves only with large numbered placards, but the jury attendants had previously assigned numbers with names announced to as many as 100 prospective jurors, and selected jurors would likely introduce themselves during deliberation. I planned to refuse to provide what in any other venue would qualify as protected health information (PHI) under HIPAA, but neither judge nor attorney ever asked. I admitted only that I have never sustained an injury in a motor vehicle accident.
I still wonder whether the court can compel a prospective juror to reveal medical information. If so this would seem to represent a double standard of sorts and would seem to conflict with or even invalidate medical privacy safeguards.
All prospective jurors also dutifully stood, raised their right hands, and said, "I do," when ordered to swear the oath. (No one seemed to notice that I did not raise my hand or say, "I do.") In that situation most seem to accord great authority to judges, sometimes assuming judges possess authority they may not really have. I doubt that a judge can compel me to swear an oath. If this is true, and if judges lack the authority to compel release of medical information, they should inform prospective jurors of this fact.
Sunday, August 7, 2011
Need Help With Drug-of-the-Day Tweets
If you had to think of two or three words to remind a potential prescriber or even a patient about some important aspect of a drug, what might they be?
Every day (repeating on the same day annually) I will tweet a different CNS drug with a link to the drug's page and a few words to remind of a key property of the drug or aspect of it's use. This is intended as an educational tool.
Yesterday's tweet:
"BehaveNet® Clinical Capsule™ #Drug of the Day: #risperidone #prolactin h
I am soliciting suggestions. More examples lithium: kidney, thyroid; bupropion: seizure.
What might you suggest for amineptine? trifluoperazine? The list currently contains more than 365 drugs including many from the DEA controlled substances list. I am also looking for suggestions on which drugs I should drop to get down to one drug per day.
You can view the list at the link below. You may need a gmail account. Please mention suggestions with comments here or at facebook.com/behavenet.
Thursday, August 4, 2011
Hung Up on Drug Classes
This WSJ article on increasing use of antidepressants illustrates at least part of the problem: Readers naturally start thinking about patients with depressive disorders, and the article alludes to recent media attention to possible lack of effect on mild cases. Only near the end of the article does the author remind us of the wide variety of uses of these drugs beyond treatment of depressive illness, some of which enjoy FDA approval. Bupropion helps with smoking cessation. Fluoxetine gained approval for Bulimia Nervosa. I frequently prescribe mirtazapine, off label, for insomnia. FDA has approved various SSRI's for anxiety disorders like Panic Disorder and PTSD.
Did I say SSRI? Here comes another dimension. SSRI refers to a mechanism of action, or just action. SSRI's (starting with fluoxetine in the US, fluvoxamine in Europe) represented an apparent improvement over the older tricyclic antidepressants. But tricyclic, like tetracyclic (trazodone) refers to chemical structure. Other chemical classes include benzodiazepine and barbiturate.
Had enough yet? I struggle with yet another category of drug class. Even if you leave out chemical class and action, and attend to what I call clinical class, which clearly includes antidepressant, anxiolytic, and anti-psychotic, several other classes seem distinct. These include sedative-hypnotic, psycho stimulant, and neuroleptic. To my way of thinking clinical implies illness or symptom. Antidepressant means attacks depression, a symptom. But neuroleptic refers to no illness or symptom, even though we usually use that class of drugs to treat psychotic disorders. I propose calling these "effect" classes and separating them from the clinical classes. Should clinical classes be a subset of effect class or a separate class on the same hierarchical level?
Clinical classes also suffer from the too frequent assumption of all or none status. Once FDA grants approval for treatment of depression few would argue with membership of the drug in the antidepressant class. Enter the controversy surrounding the evidence that antidepressants can precipitate mania in patients with Bipolar Disorder, and take for example the anti-epileptic drug gabapentin. Anecdotal reports in the literature describe cases of apparent antidepressant effect. Should we classify the drug as an antidepressant based on such scant evidence? Does inclusion in the antidepressant class imply risk that the drug may precipitate mania in Bipolar? Just how should we determine whether a drug deserves admission to a given clinical club? For many drugs it seems the original category sticks despite evidence for inclusion in other categories.
We can see the same problem with action. We may call a drug a dopamine antagonist because that action seems to dominate, but the same drug may have histamine antagonist (anti histamine) action, and others, as well.
Sometimes the context determines the category. FDA first approved divalproex for treatment of epilepsy (Think clinical class.), but when discussed in psychiatric circles we usually classify it as a mood stabilizer (Think effect class: There's no direct mention of illness or symptom.).
Separating effect classes from clinical classes will not solve the problem. Ultimately we must maintain awareness of the limitations of the designations. The need to categorize and the complexities of the task permeate human psychology and language. For an exhaustive and fascinating exploration read:
Did I say SSRI? Here comes another dimension. SSRI refers to a mechanism of action, or just action. SSRI's (starting with fluoxetine in the US, fluvoxamine in Europe) represented an apparent improvement over the older tricyclic antidepressants. But tricyclic, like tetracyclic (trazodone) refers to chemical structure. Other chemical classes include benzodiazepine and barbiturate.
Had enough yet? I struggle with yet another category of drug class. Even if you leave out chemical class and action, and attend to what I call clinical class, which clearly includes antidepressant, anxiolytic, and anti-psychotic, several other classes seem distinct. These include sedative-hypnotic, psycho stimulant, and neuroleptic. To my way of thinking clinical implies illness or symptom. Antidepressant means attacks depression, a symptom. But neuroleptic refers to no illness or symptom, even though we usually use that class of drugs to treat psychotic disorders. I propose calling these "effect" classes and separating them from the clinical classes. Should clinical classes be a subset of effect class or a separate class on the same hierarchical level?
Clinical classes also suffer from the too frequent assumption of all or none status. Once FDA grants approval for treatment of depression few would argue with membership of the drug in the antidepressant class. Enter the controversy surrounding the evidence that antidepressants can precipitate mania in patients with Bipolar Disorder, and take for example the anti-epileptic drug gabapentin. Anecdotal reports in the literature describe cases of apparent antidepressant effect. Should we classify the drug as an antidepressant based on such scant evidence? Does inclusion in the antidepressant class imply risk that the drug may precipitate mania in Bipolar? Just how should we determine whether a drug deserves admission to a given clinical club? For many drugs it seems the original category sticks despite evidence for inclusion in other categories.
We can see the same problem with action. We may call a drug a dopamine antagonist because that action seems to dominate, but the same drug may have histamine antagonist (anti histamine) action, and others, as well.
Sometimes the context determines the category. FDA first approved divalproex for treatment of epilepsy (Think clinical class.), but when discussed in psychiatric circles we usually classify it as a mood stabilizer (Think effect class: There's no direct mention of illness or symptom.).
Separating effect classes from clinical classes will not solve the problem. Ultimately we must maintain awareness of the limitations of the designations. The need to categorize and the complexities of the task permeate human psychology and language. For an exhaustive and fascinating exploration read:
Thursday, July 28, 2011
Do you know how your patients use social media?
When I participated in a typically frantic Tweetchat discussion on Health Care and Social Media (#hcsm) last Sunday (9PM eastern) the subject of patient use of social media came up. Some tweeters focused on communication among patients and providers using, for example, Facebook and Twitter, but several voiced concerns about HIPAA compliance and privacy. Although I use both in connection with BehaveNet, as far as I know none of my patients even knows that I am Moviedoc or that I publish BehaveNet.
It has occurred to me that the ability to discuss patient care in a private and secure forum might enhance that care. I envision a virtual place where all providers involved can collaborate with the patient and even significant others or other caregivers, all with the patient's consent of course. Google Wave seemed to provide the right kind of platform, but if it has not already departed it may be on the way out. It appears though that the cloud based contact management service I use might allow me to create and host invitation-only spaces where we could hold conversations and collect and share resources.
Then it occurred to me that I don't even know whether or how any of my patients uses social media now, especially whether they use these technologies to communicate with other patients or providers about illness and treatment. I resolve now to start asking with the next patient to find out whether any might want to jump in. Next I will have to pole a few primary cares and psychotherapists.
It has occurred to me that the ability to discuss patient care in a private and secure forum might enhance that care. I envision a virtual place where all providers involved can collaborate with the patient and even significant others or other caregivers, all with the patient's consent of course. Google Wave seemed to provide the right kind of platform, but if it has not already departed it may be on the way out. It appears though that the cloud based contact management service I use might allow me to create and host invitation-only spaces where we could hold conversations and collect and share resources.
Then it occurred to me that I don't even know whether or how any of my patients uses social media now, especially whether they use these technologies to communicate with other patients or providers about illness and treatment. I resolve now to start asking with the next patient to find out whether any might want to jump in. Next I will have to pole a few primary cares and psychotherapists.
Thursday, July 21, 2011
Traveling sick? WA beats MD beats MA.
As patients continue to move or travel in different states I have the opportunity to update my table of information on legality of practice of medicine across state lines.
Massachusetts gets an F
In two voice mail messages a representative of the Board of Registration in Medicine on June 30, 2011 explained, "If the patient is in Massachusetts, you would need a Massachusetts license." This applies not only to patients moving to the state, but also to patients traveling in the state. They even consider calling in a prescription to a pharmacy in MA to constitute practice of medicine, requiring a license to be legal.
Maryland gets a C
In a series of emails on July 18 and 19 a "Public Policy Analyst" at the Maryland Board of Physicians cited: Code of Maryland Regulations (COMAR) 10.32.05.03 which specifically addresses "telemedicine" in stating that even a phone call with no fee would require a MD license, but she also pointed out that the Board would not likely know and that investigation might only occur after a complaint.
In a followup message, however, the Analyst told me that MD has a reciprocity agreement with DC, so physicians and patients located in or licensed in either jurisdiction might pretend it's just one state.
But there's more: In her final message she cited: §14–302. Health Occupations Article, Annotated Code of Maryland:
"Subject to the rules, regulations, and orders of the Board, the
following individuals may practice medicine without a license:
(4) A physician who resides in and is authorized to practice medicine
by any state adjoining this State and whose practice extends into this
State, if:
(i) The physician does not have an office or other regularly
appointed place in this State to meet patients; and
(ii) The same privileges are extended to licensed physicians of this
State by the adjoining state..."
As I read the map this covers: DC, VA, DE, PA, and WV. I know of no other state with such a rational statute. Every state should enact a similar law.
Washington gets an A+
I still have to pinch myself to make sure I'm not dreaming. Yesterday a representative of the WA Medical Quality Assurance Commission repeatedly assured me that WA considers the practice of medicine to take place where the physician -- not the patient -- is located. At least for purposes of patients traveling to other states I believe this is as it should be. I have a feeling this policy will not last, but until then, if you are sick, come to Washington! Or at least if your patient plans to travel, and you the physician want to retain your status as a non-criminal, encourage all your patients to choose WA as the place to vacation or travel on business.
Massachusetts gets an F
In two voice mail messages a representative of the Board of Registration in Medicine on June 30, 2011 explained, "If the patient is in Massachusetts, you would need a Massachusetts license." This applies not only to patients moving to the state, but also to patients traveling in the state. They even consider calling in a prescription to a pharmacy in MA to constitute practice of medicine, requiring a license to be legal.
Maryland gets a C
In a series of emails on July 18 and 19 a "Public Policy Analyst" at the Maryland Board of Physicians cited: Code of Maryland Regulations (COMAR) 10.32.05.03 which specifically addresses "telemedicine" in stating that even a phone call with no fee would require a MD license, but she also pointed out that the Board would not likely know and that investigation might only occur after a complaint.
In a followup message, however, the Analyst told me that MD has a reciprocity agreement with DC, so physicians and patients located in or licensed in either jurisdiction might pretend it's just one state.
But there's more: In her final message she cited: §14–302. Health Occupations Article, Annotated Code of Maryland:
"Subject to the rules, regulations, and orders of the Board, the
following individuals may practice medicine without a license:
(4) A physician who resides in and is authorized to practice medicine
by any state adjoining this State and whose practice extends into this
State, if:
(i) The physician does not have an office or other regularly
appointed place in this State to meet patients; and
(ii) The same privileges are extended to licensed physicians of this
State by the adjoining state..."
As I read the map this covers: DC, VA, DE, PA, and WV. I know of no other state with such a rational statute. Every state should enact a similar law.
Washington gets an A+
I still have to pinch myself to make sure I'm not dreaming. Yesterday a representative of the WA Medical Quality Assurance Commission repeatedly assured me that WA considers the practice of medicine to take place where the physician -- not the patient -- is located. At least for purposes of patients traveling to other states I believe this is as it should be. I have a feeling this policy will not last, but until then, if you are sick, come to Washington! Or at least if your patient plans to travel, and you the physician want to retain your status as a non-criminal, encourage all your patients to choose WA as the place to vacation or travel on business.
Subscribe to:
Posts (Atom)
Posts
