A piece in US News and World report about mental illness and violence:
A piece in US News and World report about mental illness and violence:
The British Medical Journal (BMJ) recently printed a piece highlighting many of the problems with state Physician Health Programs (PHPs) that I have been writing about for several years. You can find the BMJ piece here:
I am so grateful that these issues are finally getting the attention they need. My own work was cited twice in the piece, which was nice also, but mostly it feels like there might be some light at the end of the tunnel. All that is needed is for PHPs to begin to operate transparently, with real oversight, create and adhere to national standards of operation, and cease their ties to evaluation/treatment centers with whom they have significant financial (and other) conflicts of interest.
I had a letter published in the Globe today:
Re “How to provide Medicare for all” (Opinion, May 18): As Dr. Marcia Angell notes, the insurance industry profits by refusing to pay for needed care or else simply denying claims.
Insurers also have more insidious ways of turning a profit. One of these ways is to require time-consuming prior authorizations for certain services in apparent hopes that clinicians will be discouraged from trying to access those services.
In a study colleagues and I conducted, we found that emergency mental health care workers spent an average of one hour on the phone with insurers, obtaining permission to hospitalize suicidal youth. Given that authorization ultimately was granted in every single case, this is an administrative hassle whose sole purpose seems to be to dissuade clinicians from seeking care they deem necessary for their patients, even though every extra minute spent in an emergency room increases risk for both the patient and health care workers.
Another way insurers profit is by not maintaining accurate lists of providers who are in their network and accepting new patients. In a separate study, we used insurer databases of supposedly “in-network” providers and found that many practices were full and that the list was replete with wrong numbers. We were only able to secure appointments 26 percent of the time.
Insurers have no incentive to ensure that people receive timely, needed care. As Angell so eloquently notes, they need to be removed from health care entirely and replaced by a not-for-profit system whose sole motivation is to get people the care they need.
Dr. J. Wesley Boyd
The writer is an associate professor of psychiatry at Harvard Medical School and a faculty member at the school’s Center for Bioethics.
I recently posted another slide presentation on QuantiaMD, this time about physician health programs entitled State Physician Health Programs: What You Need to Know. You can find it here.
In the comment section following my presentation, one respondents writes the following: “I was, as far as I know, physician #1 in the State of Wisconsin physician health program, and later served on our county medical society PHP. Still later, after moving to the RI/MA area, I served on both of those states’ PHPs. I am now retired and no longer actively involved with them. I think Dr. Boyd fairly states the positives and negatives of these committees, but perhaps understates the issues related to both lack of a fair due process, as well as the tremendous conflicts of interest that result in virtually 100% of referrals being considered impaired or in need of “further diagnostic evaluation.” As a physician who has worked in chemical dependency treatment for over 30 years, I do not need that level of time, effort or expense to do a totally satisfactory evaluation of my patients, both health professionals and others. The drawn-out, very expensive and usually very 12-step driven treatment has no comparator in any evidence base. We treated over 20 physicians at our community hospital program, with 18 of them highly successful, without the rigamarole of a 90+ day >$100.000 referral to Big Name Treatment Centers (our average cost, which included family involvement and either a 2 week Day Treatment Program or a 6 week Evening Treatment Program, followed by 1:1 counseling for at least 6 months, was about $10,000. Unfortunately, our PHP has chosen to only use the very expensive programs for both diagnostic and treatment referral, and unsurprisingly they continue to believe every physician referral has a problem and are all in denial. Many area, but many are not, and I do not find that these programs make the necessary efforts to contact collaterals and chase down the facts.”
A study that colleagues and I authored is being published online today in American Journal of Emergency Medicine. Here is the press release for the paper:
A study published online on March 3 in American Journal of Emergency Medicine found lengthy waits for severely ill child and adolescent psychiatric patients in need of immediate hospitalization due, in part, to time consuming prior authorizations required by insurance companies. Mental health workers spent, on average, 60 minutes on the telephone obtaining authorization. In one case obtaining authorization took 4.5 hours. Over half of these youth who required hospitalization were suicidal, and a substantial minority were aggressive, assaultive, and or homicidal.
Four million children and adolescents in the US suffer from a serious mental disorder that causes significant functional impairments at home, at school and with peers. In youth, many of these disorders can have life-long deleterious effects. Timely access to care might reduce the harms mental illness imposes on youth, along with their families and communities.
For the present study, over a 5 month period, psychiatric clinicians in the Hasbro Children’s Hospital emergency room (ER) in Rhode Island tabulated data each time they contacted an insurance company on behalf of a child deemed in need of psychiatric admission. Patients ranged in age from 4 to 19 years old and the most common reasons for admission included suicidal ideation or a suicide attempt (56%), aggression (22%), and homicidal ideation (10%). The average time required to obtain authorization from the insurance company from the time of first contact to authorization was 59.8 minutes. The time spent on these calls simply added to the total time these children spent in the ER prior to being admitted to an inpatient unit. Every single request for admission was granted.
Given the total number of psychiatric admissions nationwide each year, 60 minutes of phone time to obtain authorization translates into over a 1,500,000 hours of wasted clinician time. The cost of this wasted time is staggering. One nationwide study of the time that physicians and other practice administrators spend interacting with insurance companies calculated that the annual cost to our health care system for all physicians nationwide to engage in these non-reimbursable interactions was approximately $31 billion.
Lead author Amy Funkenstein, MD, currently on staff at Tufts University, led the study while she was a child psychiatry fellow at Brown University, noted: “Psychiatry is singled out for this kind of scrutiny. Pediatricians do not have to contact insurers prior to admitting a child with pneumonia. Obstetricians do not have to do so if a woman is in labor. Surgeons do not have to haggle with insurers if a patient has acute appendicitis. These onerous prior authorization requirements that single out the most severely ill psychiatric patients should be halted. Given that the need to obtain prior authorizations can extend what is already a lengthy emergency room stay, I wonder if the need to obtain prior authorizations represents a violation of either mental health parity or the Emergency Medical Treatment and Active Labor Act.”
Senior author J. Wesley Boyd, MD, PhD, a psychiatrist at Cambridge Health Alliance and an Associate Professor of Psychiatry and a faculty member at the Center for Bioethics at Harvard Medical School, commented, “Private insurers prey upon those with mental illness. Healthcare workers are already overburdened and to add this requirement for prior authorization is unconscionable. It violates any notion of parity for those with mental illness. Insurers hope that clinicians will be so hassled by authorization procedures that they won’t seek admission for their patients, and less utilization of services means greater profits for the insurers. Once again, insurers are placing profits ahead of patient safety and well-being. If we didn’t have a profit driven healthcare system this simply wouldn’t be happening.”
The paper concludes by saying, “Insurance reviews and pre-authorization requests are just a part of what makes accessing needed psychiatric care difficult for children and adolescents, given that finding comprehensive services for children is only possible in certain parts of the country. Adding prior authorization to an already difficult process, especially for psychiatric patients who are deemed to be of “imminent risk” to themselves or others, seems both dangerous and predatory. Onerous prior authorization requirements that single out the most severely ill psychiatric patients should be halted. It burdens our psychiatric clinicians and functions to limit care by placing time consuming bureaucratic burdens on clinicians rather than meaningfully evaluating patient’s needs.”
I didn’t know anything about this piece in Mic.com until a colleague at CHA pointed it out. The article makes the point that even though heavy users of marijuana don’t experience the dramatic withdrawal effects that heavy users of alcohol or opiates might, for a small minority of users marijuana is nonetheless addictive.
Just released piece on QuantiaMD about referring a colleague to a PHP. Find it here.
If the US actually supports our Constitutional right to free speech, then both of these individuals deserve an award from our country.
My paper of the same title was just published in the Journal of Addiction Medicine. The title sums up the essence of the paper, namely that since other healthcare entities (such as hospitals and residency training programs) are subject to outside scrutiny, routine audits, and must conform to agreed upon standards, Physician Health Programs ought to be no different. The link below is to the final proof prior to publication:
I have a new piece out in the AMA Journal of Ethics about physician health programs. You can find it here.