Physician Patient

Archive for the ‘Message from the President’ Category

Penalties for Quality Continuity of Patient Care

Friday, December 27th, 2019

Cost-effective continuity of patient care is deteriorating in our current medical care system. The lie: Hyped claims of patient-centered care while money is made as patients “fall through the cracks.”
Can money for care follow the patient’s clinical needs rather than algorithmic rules of money changers and corporate mangers (such as penalties for re-admissions)? That was a key question for us on Gov. Rudy Perpich’s Mental Health Commission in 1985. See:
And it still is.
Let’s consider psychiatry as the canary in the coal mine.
As psychiatry residents at the University of Chicago (1966-69), we were assigned the expectation and given the responsibility and power to move patients in and out of UC care settings and level of care that we deemed were appropriate to the patient’s current clinical needs.
Similarly, when I was a staff psychiatrist at the Metropolitan Medical Center (MCC) in Minneapolis (1972-84), I worked closely with a hospital nurse Team Leader who kept track of patients assigned to me.  She (or another psych nurse on call) would go to the ER whenever a patient (of ours) showed up — or to begin the work-up of a new patient when assigned to the medical staff ( See: Passion for Patients The nurse Team Leader accompanied me on hospital rounds. MMC also supported an outstanding hospital-based psychiatry outpatient department featuring group therapy programming for patients. Patients under my care with a hospital history could also to show up at “Nuclear Group”convened at the hospital if they had a self-defined “crisis.”  And, I had the option to see patients at my private office as well.
Money for their care followed patients more closely than it does today.
In a message dated 12/26/2019 4:55:37 PM Central Standard Time, writes:
So,  a patient with a chronic condition,  such as CHF,  is almost always admitted in “observation” status,  as the rule is that the number of days allowed for treatment is too few,  so they are often discharged unstable.  Further,  many patients are not compliant with their treatment,  especially dietary and exercise.  So back they come.  There are huge fines if such patients are admitted again within a 30 day period.  Hence not admitting them in the first place,  and calling them observation status,  which is not covered by insurance nor Medicare,  incurring huge surprise expenses.  This has become extended to lots of other diagnoses,  such  as broken bones or surgeries.  Most recently,  there was an article by a physician,  whose prostatectomy for prostate cancer was not covered,  as he was admitted as observation status.  Any doc who reveals this to the patient or complains is likely to lose their job quickly.
These metrics are clearly wrong,  yet I see no one trying to get around them by making them public and pushing to have them changed or stopped.  Instead there is an effort to deflect them onto the patient.
Apparently below  is a rule by which this metric mess is defined.  Just another situation we must ALWAYS check out if we or anyone we care about is admitted to the hospital.  Insist on a real admission.
“All metrics of scientific evaluation are bound to be abused. Goodhart’s law (named after the British economist who may have been the first to announce it) states that when a feature of the economy is picked as an indicator of the economy, then it inexorably ceases to function as that indicator because people start to game it”There is an entire book recently published devoted to this issue :
“The law is richly illustrated in the 2018 book The Tyranny of Metrics by Jerry Z. Muller. An enunciation of the law preceding both Goodhart’s and Campbell’s works is due to Jerome R. Ravetz. In his 1971 Scientific Knowledge and Its Social Problems,[9] pp. 295–296, Ravetz discusses how measurement systems can be gamed. For Ravetz, when the goals of a task are complex, sophisticated, or subtle, then crude systems of measurements can be played exactly by those persons possessing the skills to execute the tasks properly, who thus manage to achieve their own goals to the detriment of those assigned.”

Up to their old games: Minnesota insurance companies are denying mental health claims

Wednesday, November 6th, 2019

Up to their old games?
Undeniably, denying claims is the managed care business model. “Captain may I” managed care prior authorizations and claims denials are the dominant health care rationing strategies of Minnesota insurance companies and third party administrators (TPA) contracted by self-funded corporations.
United Healthcare (which originated in Minnesota) is the reigning champion of these practices.
Claims denying is used extensively for managing mental health claims. That’s why mental health advocates pushed for mental health parity laws. However, the deal-breaking caveat for implementing state and federal mental health parity laws to expand coverage is this: Medical necessity is determined (defined and decided) by the managed care company itself, not by the patient’s health care “provider” (physician, psychologist, social worker, etc.), or an independent arbitrator, or most importantly by the consumer (patient and family). And the denials can occur before, during, or after treatment is provided.
I left employment as a mental health medical director at a large Minnesota PPO years ago because I couldn’t work for an enterprise that advertised and competed with other managed care companies touting its effectiveness in denying patients’ mental health claims.
How best to fight third party mental health claims denials? Stop contracting with third parties. Most Minnesota physicians are now employees and their organizations do the dirty work. Independent doctors can be paid by their patients. And patients themselves can get payments from their insurance companies.
Complaints and public pressure require tireless and Sisyphean efforts on the part of both doctors and patients. The managed care stone always rolls back on one; its corporate economic power and mass exponentially growing. When patients have skin in the game they will complain. And patients’ complaints matter most when they are reinforced by other patients and community mental health advocacy organization such as NAMI-Minnesota. Or if the rolling stone is an asteroid law suit involving lots of public money and taxpayers. [See the Westin case and MN AG Mike Hatch’s suit against BCBSM in 2001]
Uncollected accounts receivable in a private practice? The bigger they become the more the doctor is pushed into giving up her independent practice. That’s part of the UHC playbook as well.