Sunday, August 31, 2008

Write on that Slate?

Now here's the next question in my Questions to Ponder Series:

When I asked if it's okay to give a referral for a gay therapist, several readers wrote in saying that it's not reasonable to "out" another therapist. Fair enough. Other readers wrote in implying that the patient's concern should be examined, that it's part of the treatment to use the patient's concerns to help them learn about themselves, Grist For The Mill, so to speak.

I'll take it as a given that a) therapists/people-in-general have the right to their privacy and some things they may feel are personal and they may not want to share with their patients/other-people, and b) therapy should be about the patient and it's an abuse of the patient's time to spend it talking about the therapist's personal life in any detail.

Aside from those facts: How exactly does it damage the patient's treatment if he knows some information about a psychotherapist's personal life? Do we really truly believe that there is a difference in treatment outcomes if a therapist wears a wedding ring or doesn't? If he answers a question about where he went on vacation or if he has children?

Saturday, August 30, 2008

CPT Billing Codes for Psychiatrists and Psychotherapy

Joseph j7uy5 over at Corpus Callosum posted a review of some articles in the recent issue of Archives of General Psychiatry.  One of the articles was "National Trends in Psychotherapy by Office-Based Psychiatrists" by Ramin Mojtabai & Mark Olfson (Arch Gen Psychiatry. 2008;65(8):962-970).

He linked to an LA Times summary of the article, which suggested that medications were increasingly "replacing" psychotherapy.  Joseph's take on the newspaper article was right on the money... that the article did not address whether medications were "replacing" psychotherapy, but "Instead, what the study says, is that psychiatrists are, on average, spending a smaller proportion of their time doing psychotherapy. It is possible (indeed, likely) that other practitioners are doing the psychotherapy, while the psychiatrists are devoting more of their time to medication management."

I'm going to go one step further and say that it doesn't even say that (though it still is probably true).  What the study says is that psychiatrists are billing for fewer and fewer psychotherapy visits.  Click on the image above and it takes you to a .pdf of the form that survey participants used as part of the National Ambulatory Medical Care Survey, which is what this study is based on.  It's a lot to complete, and I'm guessing that participating psychiatrists had an office staffer complete these forms.  And the office staff probably decided whether to darken the psychotherapy square only for patients scheduled for 45 minutes or an hour.  Or, maybe based on the billing code used.  I doubt that they asked the doc after each visit if she "used psychotherapy" with the patient.

Anyway, here is what the study "found":
Results:  Psychotherapy was provided in 5597 of 14 108 visits (34.0% [weighted]) sampled during a 10-year period. The percentage of visits involving psychotherapy declined from 44.4% in 1996-1997 to 28.9% in 2004-2005 (P < .001). This decline coincided with changes in reimbursement, increases in managed care, and growth in the prescription of medications. At the practice level, the decrease in providing psychotherapy corresponded with a decline in the number of psychiatrists who provided psychotherapy to all of their patients from 19.1% in 1996-1997 to 10.8% in 2004-2005 (P = .001). Psychiatrists who provided psychotherapy to all of their patients relied more extensively on self-pay patients, had fewer managed-care visits, and prescribed medications in fewer of their visits compared with psychiatrists who provided psychotherapy less often. 
Conclusions:  There has been a recent significant decline in the provision of psychotherapy by psychiatrists in the United States. This trend is attributable to a decrease in the number of psychiatrists specializing in psychotherapy and a corresponding increase in those specializing in pharmacotherapy—changes that were likely motivated by financial incentives and growth in psychopharmacological treatments in recent years.

I wasn't able to find my issue of AGP around the house, but I'm sure that these limitations of the study were discussed.  Nonetheless, I'm not here so much to critique an article I didn't read as I am to explain about how psychiatrists bill for their services.

So, anyway, I submitted a comment to Joseph's post, which wound up being so long I thought I'd post it here, regarding how psychiatrist office visits usually get coded, or billed. 

When psychiatrists submit a bill to an insurance company, there are generally 3 types of codes one can use, which are called CPT codes (for Current Procedural Terminology). One is called an E&M code (Evaluation & Management). This would mostly be one of these: 99211, 99212, 99213, 99214, 99215 (each one is more complex or time-consuming than the next, with escalating payments). Use of this code requires a specific type of documentation. A number of insurance companies may either not pay for this code for psychiatrists, or require a preauthorization.

The next are psychotherapy codes, which are based on time and the main ones are 90805 (20-30 min), 90807 (45-50 min), and 90809 (75-80 min). These also require some specific documentation and payments escalate.  (There are other codes which are used when there is no E&M component, such as 90804, 90806, 90808, but most psychiatrists actually do evaluate and manage treatment with each visit, though they may use these even codes if they don't want to bother with the documentation, which can be quite onerous.)

Finally, there is the medication management code, or 90862. There is no time attached to this one, so whether you spend one minute or one hour with a patient, you can use this one. It is paid about the same as a 99213 and a bit less than a 90805. There are very little documentation requirements and rarely requires a preauthorization, so it is the easiest one to use. Many psychiatrists will use this code, yet still provide psychotherapy to a patient during the session, commonly 15 to 30 minutes long (a few docs may only see pts for 5 or 10 minutes, if the pt is well-known to them, or in a busy clinic, but this is probably not the standard).

So, since the abstract was unclear on this matter, I thought I'd do some teaching about how it works. Given how the study was done, I think that it only truly speaks to the success of managed care policies in paying less and less for psychiatric treatment. Of course, you get what you pay for.

Friday, August 29, 2008

When Lawyers Call

Clink is on "lockdown" whatever that means. It can't be good and it seems to mean no access to the blog, so she asked me to post this for her. What are friends for, if not posting for you when you're indisposed? Judging by the length of this post, it seems ClinkShrink may have been locked down for some time now. Hoping she's free soon.

When Lawyers Call
--by ClinkShrink

One of the advantages of being a forensic psychiatrist is that you can
interact with lawyers without breaking into a panic. Occasionally I get
calls from colleagues who have been contacted by a lawyer about
something, and I can almost hear them sweating over the phone. So, I
figured it might be helpful to write a blog post about what to do when
an attorney calls.

First of all:


I can't say this enough. The first automatic thought you will have is
that you have been drawn into something that will cost you a lot of
time, money and emotional distress. That's almost never the case.

The most common thing that happens is that you might get a subpoena.
This is usually sent by U.S. mail, but occasionally is hand-delivered
by a process server. If you don't read Latin (all great legal documents
are written in Latin) you won't know that there are two types of
subpoenas: a "subpoena duces tecum" and a "subpoena ad testificatum". A
duces tecum means that the lawyer just wants records from you. The
other type means that the lawyer actually wants you to appear for a
hearing to give testimony. Regardless, subpoenas will pretty much
always involve a patient you are treating and you may already know if
your patient is involved in some type of litigation. If you have a high
volume practice or a practice with a limited amount of treatment
contact---say, an emergency room or consult liaison service---you may
not remember the case. If a review of the patient's chart doesn't
suggest the reason for the subpoena you will need to contact the lawyer
to find out why you were served.

If you work for a hospital you're in luck---the hospital attorney
should be informed immediately about all subpoenas, and you can ask
them for advice about what to do next. The hospital attorney can call
the serving lawyer and tell you what the 'official' response should be.
The best outcome is that your lawyer will successfully file a "motion
to quash". This means that he or she tells the court that it's not
necessary to subpoena you because either: 1) the information you have
is completely irrelevant to the legal issue at hand, or 2) the
information can be obtained through the records alone, you have nothing
to add beyond that, and your actual testimony is unnecessary. In other
words, he makes the subpoena go away. Your life goes on as usual.

If you don't have a lawyer, or if you don't want to pay a lawyer how
much it will cost to do all this, you will have to call the serving
attorney yourself. The first rule to remember is: collect information,
don't give information. This is the information you need to collect: 1)
who is your client?, 2) what is the legal issue?, 3) what information
do you want from me about this legal issue? You shouldn't offer any
information at all until you have these three basic questions answered.
Specifically, don't say anything about a patient's diagnosis,
treatment, treatment compliance or prognosis. The lawyer calling you
may not be acting on behalf of your patient and there are a myriad of
reasons why you might get contacted: a contested custody case, a
disability or workmen's compensation claim, a personal injury case or
even a criminal proceeding. You could unintentionally harm your patient
by giving information to an opposing lawyer.

You're probably wondering why I didn't specifically say you should
notify your patient first. I list that as the second thing to do
because most often the person contacting you has been retained by your
patient and he or she already knows about it (you might need to have a
discussion at your next session about why they didn't warn you this was
coming!). If this isn't the case, then you need to do some preliminary
data collection in order to tell the patient what's going on. Thus,
patient notification comes second in line to talk to the serving

If the serving attorney is working in opposition to your patient, then
you need to consult with your patient about how to respond. If he or
she wants you to participate in the proceedings or to provide records
then all is right with the world. You might want to prepare them for
what you will have to say, but that's about it.

Things get messy if the patient doesn't want you involved. At this
point the number of possible hypothetical situations make it impossible
for me to cover all of them, but generally this is when you need to get
a lawyer. In certain situations the patient may not have the right to
claim (or by statute will automatically waive) privilege. You will have
to be involved regardless of the patient's wishes. You will need to
address this with the patient and consider how this will affect your
therapeutic relationship.

Finally, there is one thing I strongly advise you not to do:


It will not go away. Failing to respond could put you at risk for
monetary penalties. In a worse case scenario, a judge could sent out a
"body attachment" on you. In other words, sheriffs show up in your
office to physically take you to court. I've never heard of this
actually happening to a doctor, but I don't want any of our readers to
be the first one.

OK, I think this post just made up for weeks of ClinkShrink inactivity.

Wednesday, August 27, 2008

Things to Ponder

I've decided to start a series of thought-provoking (I hope) scenarios. These aren't real patients, they're just food for thought. Please chime in.

So how much should one psychiatrist say to his patient about another psychiatrist? Here's the specifics-- a patient wants a referral for her friend. The friend is having difficulties related to his sexual orientation and the patient asks for the name of a gay therapist to give to her friend. She's only asking for a name, nothing about insurance or the specifics of any mental illness. Is it okay for the psychiatrist to give her the name and phone number of a gay psychotherapist to give to her friend? What are the assumptions that are being made here and is this a reasonable thing to do?

Tuesday, August 26, 2008

Places I'd Rather Be

Addendum: Here is an old post on "No Shows" which is a completely different phenomena than leaving early....

I've vowed never to put real patient stories on the blog. Tonight, I'm saying, "What the hell." The following is not confabulated.

Over the years, I've been stood up for oh so many reasons. Martial arts class sticks out among them. Forgotten meetings, forgotten dates, forgotten children...they've all been reasons to forget a therapy session. No one that I'm aware of has ever canceled an appointment at the last minute for a hair dresser's appointment, but maybe I just don't know. Today a patient left early. Why? Had to get those fantasy sports picks in. This was a first. Roy would have passed over the iPhone and been done with it. I'm not so accommodating and I don't have an iPhone, 2g, 3g or otherwise.

I hate it when patients simply don't show up and don't call-- when I spend an entire session pacing back and forth to the waiting room and can't use my time. If people opt out because life is busy and the choices are too many, I can't say I mind. It's their life, it's their right to define priorities, as long as my time isn't wasted or someone else isn't left wanting for that session, then hey, Fantasy Picks, what can I say? I'm not one for being judgmental or shoving down someone's throat that therapy needs to be their top priority: that's for them to decide, especially in a long-term therapy with a stable patient. Sorry, there's no pro-rating for judo class, fantasy sports, whatever. Life is busy and we all have to make choices.

Sometimes I think people should cancel their sessions. Get your hair permed at a different time, but for someone who's had trouble finding or maintaining employment, well...they should cancel therapy sessions (or schedule outside of work hours) for the first few weeks of a new job. "Gotta blow this crab feast for an hour" the first week on the new job just doesn't feel wise.

Well, I hope my patient got the good players.

Sunday, August 24, 2008

What I Read On My Summer Vacation

I spent 13 nights away on vacation-- the longest I've vacationed for in many years. It was wonderful; I returned relaxed, at peace, feeling like a new person. I live for vacation.

So vacation was just short of 2 weeks because the teenagers wanted to attend the first day of VirginMobileFest and we all went (separately, of course, they wouldn't be caught dead with me) to hear a variety of bands play-- the Outkasts, Jack Johnson, Foo Fighters. I thought I'd be bored, but it was a gorgeous day here in B-More and I had a great time. Sort of reminded me of being young again, sans kids, with my main squeeze as an all-day date.

We went to Mission Beach in San Diego-- a great mix of a city vacation and a beach vacation all rolled into one. The zoo, the Padres, we sailed, biked to La Jolla, kayaked, sun bathed, restaurants and funky parts of town. Our deck looked out on Mission Bay and I loved the mornings, coffee cup in hand, to sit and read.

There's this thing I have about vacation: I love to read. I concentrate better than I ever do at home, and pretty much anything compels me. I used to think it was because I have more time, but it's not just time. At home, I read in sound bites: blog posts, journal articles, on-line newspapers, The NY Times magazine. I limp through books, even novels, a few pages at a time. On vacation, I ingest them. And when I'm done, I read other peoples' books.

So here's what I read on vacation:

Dreams from My Father: A Story of Race and Inheritance by Barack Obama, 1996
A fascinating account of our presidential hopeful's youth. He portrays himself as a caring, idealistic young man, full of hope, energy and dreams. He deals with some very painful childhood issues in a somewhat distant way--- I guess the psychiatric term that comes to my mind is 'well-defended.' Quite a life.

Run East: FLIGHT FROM THE HOLOCAUST By Jack Pomerantz, Lyric Wallwork Winik

This was actually a re-read of a book I'd read years ago: a man's story of leaving and losing his family when he leaves Poland to escape the Nazi invasion. He spends years as a refuge in Russia, in a story that moves from tender and often hopeful, to often simply horrifying.

Asking for Murder
by Roberta Isleib. Dr. Isleib is a psychologist/novelist and she writes about a psychologist/advice columnist who's best friend, a social worker who specializes in "sand play" therapy, is beaten into a coma. A beach read (and that's where I read it). ClinkShrink wants to do the official review, but the book was sent to my office-- a perk of being a Shrink Rapper.

Playing for Pizza by John Grisham. Football player messes up his career and ends up playing in Italy where he finds himself. Reminded me of Eat, Pray, Love. Another beach read. I like his legal thrillers a lot better. Lots of football here. Borrowed from teen son.

Tally's Corner, A Study of Negro Streetcorner Men by Elliot Liebow, 1967. Actually, the research for this book was done in 1962 and it's the author's doctoral dissertation. He spends his time hanging with those who live on the margins of survival and writes about their poverty, their struggles, their families, their relationships, and their place in society. Okay, so it now takes more than 70 cents a day to feed a person, and if you ignore the impact that computers and video games may have made, the stories told somehow feel they could be happening today. That we haven't come further is a tragedy.

by Sarah Dessen, 2000. Caitlin has the perfect life, until her big sister runs away two weeks shy of starting her freshman year at Yale. Caitlin makes the cheer leading squad and soon finds herself in love with a boy who beats her mercilessly. She loses her self, the truth of it all gets found out, a few months in a psychiatric facility and voila, Caitlin's good as new. Borrowed from teen daughter.

Home again, home again. Let the chaos resume.

Monday, August 18, 2008

Psychiatrists in August....

(ClinkShrink note: I'm posting this on behalf of our missing-in-action co-blogger, Dinah. Here's hoping she gets back quickly.)

It's been a bit quieter than usual here on Shrink Rap.

Oh, it's August, the month when psychiatrists traditionally go on vacation. If we were Manhattan psychoanalysts, then perhaps we'd all be in Wellfleet, sitting on the beach, talking about our unresolved complexes, or whatever. But we're not Manhattan psychoanalysts. We're Shrink Rappers.

Funny thing, though. We've all gone on vacation in August. This is for Phoebe who commented that we all suddenly disappeared.

Roy went to Acadia in Maine. ClinkShrink went to Acadia in Maine. Funny, she deemed this completely coincidental, but it's Roy's second year in a row and he sent back such beautiful photographs (--the guy has talent) from last year that I believe they tweaked at something deep inside of Clink and she, too, just had to be there. See, I could be a psychoanalyst. Of course, you can see Roy's vacation photos, including his flat tire on Day #1 [Roy: I took them down as they were meant to be temporary and not enduring psychiatric reading], or read about ClinkShrink's life-threatening mountain climbing, on posts from earlier this month right here on Shrink Rap.

I'm still on vacation. Actually, I live for vacation. I'm in sunny, gorgeous, Southern California, soaking in the sun, eating great food, getting a fair amount of exercise (sailing, biking, walking, jogging, visiting the gym, sightseeing). I'm pleased to report that we've done nothing to endanger our lives here.

So why do psychiatrists go on vacation in August? I want to venture a guess that psychiatrists vacation in August for the same reasons everyone else does. Personally, it's not my favorite time to be gone-- I like working when there's no traffic, fewer patients (they all go on vacation, too) and I'm not crazy about the heat (hence, Southern California). August, because the younger teen is back from camp and school hasn't started yet. When my kids are grown, I have every intention of vacationing in September, when the crowds are gone and the prices are cheaper.

It seems to me that in many professions, the world slows in August and December. It's a pace I prefer, and I often wonder why we can't just pretend that it's always August.

I found only one 1964 study looking at day hospital patients' reactions to August vacations.  Half felt better after the day hospital closed for a month for vacations and half felt worse.

I'm Proud of My 'Kids'

I have a nice little cadre of students these days. They are young, bright, enthusiastic and at times a little anxious and intimidated. They are a wonderful group, and it's my job to figure out the best way to teach them what they need to know. They have a lot to learn and a limited amount of time to learn it in. Information is being thrown at them fast and furiously from several faculty sources. It's their job to catch it, retain it and somehow organize it for future use.

Eesh, I'm glad I'm not in their position anymore. It's tough.

People learn differently, and from year to year each group of students has their own preferences about teaching methods. Some want lectures, some want case conferences, and some just want to be left alone to read on their own. I find that we tend to cycle through these preferences on a regular basis, responding each year to the preferences of the previous years' students while hoping that some day the two years' preferences will match and all will be happy.

That's never going to happen, but I don't mind trying. I like the idea that some day years down the road I will have a group of folks whom I've helped propel along the professional path and whom someday I'll be pleased to call my colleague. It's the next best thing to having kids, without the driving lessons and diaper changes.

Saturday, August 16, 2008

Help The Future Psychiatrist

My nephew wants to be a doctor. Specifically, a psychiatrist. What could I say? I'm biased, but I think it's a great choice. The world of medicine is pretty challenging these days and a doctor's lifestyle in training can be a grind, but if I had to do it over again I'd do the same thing. He's looking for a chance to get some additional research experience while he applies to grad school, so I agreed to put up a blurb for him. If anybody knows how he can do some interesting psych-related research in the Berkeley area (or online), for free or for pay, please comment here or drop an email. Here's what he has to say for himself:

Hello, world! This is the ClinkShrink's nephew, of roughly the same level of nerdiness but sans guinea pig obsession. :)

I recently graduated from Berkeley with a degree in molecular neurobiology (and one in architecture, of all things), and am currently paying off student loans working on a SAMHSA study (DAWN project) and writing policy for the city of Berkeley while applying for MPH programs for fall 2009. I have the goal of getting an MD or PhD after that. I'm fixed pretty firmly in Berkeley for at least the next year, but would be interested in helping out--for pay or volunteer--in some additional research work via telecommuting.

Clink suggested the blog could be a means of finding out about these opportunities.

My primary interests lie in tying emotional/cognitive psychology to neurobiology, particularly where clinical treatments and disorders are involved. I certainly wouldn't turn down other interesting psych work, though, and just in case you were curious, my dream Nobel Prize would come from elucidating a physiological basis for consciousness (whatever that may end up meaning).

For the physicians out there, I'm much more interested in internal medicine and therapy treatments than surgical intervention, but again at this point I'm not ruling anything out off the bat. Email ShrinkRapBlog at or comment here if you know of any thing like this, and Clink will forward the info to me.

Cheerio, and thanksa!

Monday, August 11, 2008

Climb Every Mountain

Subtitle: "Blood On The Bike"

I'm back from vacation. Roy's been posting about his camping experience in Maine and by pure coincidence I also planned my summer vacation to Acadia National Park. I called Roy and tried to catch up with him, but for the most part I didn't have cell phone coverage when I was there.

Let me start by saying: it was wet. More than wet, it was a deluge that first day. The tent held up with only mild dampness, but I knew I was in trouble when a park ranger stopped me on the way back from my hike to warn me to take shelter. He said there were 60 mile per hour winds predicted, with lightening and hail. Yes, it was wet. There wasn't any hail and the wind wasn't that bad, but we did get three waves of lightening storms through the night. Since it couldn't get any worse, I went for a swim in the ocean in the rain. Cold truly can be painful, and that water was frigid.

Day Two was drizzly and overcast, but clear enough to ride bikes. I made it up Cadillac Mountain (1500 foot elevation) at all of about 4.5 miles per hour. It took about an hour to get to the top, but the ride down was fantastic. I had to keep braking the whole way down to keep from flying off the edge of the switchbacks. I was at the bottom in about seven minutes.

Day Three finally gave us a break in the weather, enough to get some hiking and more biking time, as well as a nice sunburn sitting on Sand Beach.

The most unique part of the whole trip was the climb up Mount Champlain. Now, this climb is optimistically referred to as the Precipice Trail but it's not a hike by any stretch of the imagination. It's pure rock climbing. There's a sign at the bottom of the mountain that warns people not to bring children up because people have died on the climb. I was too busy trying not to slip, digging my fingernails into solid rock, that I didn't take any pictures. Besides, I knew some other brave or foulhardy soul with better photography skills had probably already put some pictures up on Flickr so here is a link to those pictures of the Precipice Trail. (It's steeper than it looks in the pictures.) I've never been so terrified. There are iron rungs you can climb, but what they don't tell you is that when you're as short as I am there is sometimes a gap between rung sets that requires you to traverse over a narrow sloping ledge that hovers over a steep plummet. By the time I got back to the base I wanted to shout "You're all going to die!" to anyone starting up the trail. I resisted.

By this time I was dirty, sunburned, sore and needed a hot shower. Badly.

Thank goodness for Isle Au Haut. More specifically, for the Inn at Isle Au Haut. It's beautiful but isolated, and you can only get there by mail ferry. Innkeeper Diana Santospago took me in, tucked me into an amazingly soft bed and then fed me incredibly good food for two days. I had sea scallops with cream sauce, squash fritters, mushroom onion soup, soft-shelled lobster, stuffed squash, triple chocolate cake surprise (you have to guess the surprise), as well as hand-packed lunches for the day trips. I wasn't surprised to learn I had gained a couple pounds while camping in spite of the 1500 foot bike ride up the mountain, the climb up Mount Champlain, and the 50 mile ride I took after I got back to Acadia. The Inn was a perfect break even for a seasoned camper. The side trip to Isle Au Haut was rounded off nicely by a stop at Black Dinah's chocolate shop where I took shelter from yet another downpour. (Well OK, the truffles were a good reason to stop, too. They were delicious, not to mention quite beautiful.) I was treated to a short game of Scrabble to while away the time until the ferry took me back to the mainland.

OK, so to tie this in to psychiatry---this is a psychiatry blog, right?---I have to mention that I didn't really 'get away from it all'. During one breakfast stop I couldn't help overhearing the man at the next table explaining to his party what the Mini-Mental State Exam was and what it was used for. And at the Inn, one of the other people staying at the Inn while I was there was a psychiatrist. It's a wierd, small world but fortunately still a protected and well-tended one at Acadia National Park.

Thursday, August 07, 2008

Please Don't Eat Me

The usual discussion revolves around whether those who seek treatment for mental disorders should be called "patients" or "clients."

So Roy and I were at a legislative mental health meeting and one of the people giving testimony kept referring to psychiatric patients as "consumers." Consumers? Okay, it's not the first time I've heard the term, but here it was used over and over (and over) again. Consumers. I suppose I think of myself as a psychiatrist who treats patients, and not as a 'provider' to 'consumers.' This meeting took place around the same time that one of our readers commented it was insulting when I referred to a patient with recent and repeated episodes of dangerous behavior as a "time bomb" after she stopped her medications precipitously. I was thinking about the power of language, the innuendo of words and phrases, and I was struck by the repeated reference to Consumers.

It brings to mind, for me, this odd anxiety that my patients will eat me alive. Doesn't one consume food or fuel? Does one consume psychiatric services? What exactly does one consume during a psychotherapy session? What's there at the beginning that's gone by the end?

Can someone please tell me why anyone would want to be a consumer rather than simply a patient? Please don't pass the ketchup....

Oh, and my graphic of the person eating lobster is in honor of Roy's vacation posts from Maine. Please, please, do consume one for me.

The Beginning of the Middle of the End of Medicare

The Beginning of the End of Medicare was when Congress passed the rules which require physician fees to follow a Sustainable Growth Rate or SGR,  followed by the Medicare Modernization Act or MMA, which added the prescription drug plan but prevents Medicare from negotiating lower rates from Big Pharma.  The problem with the SGR is that its calculation is fatally flawed, requiring increasing annual reductions in physician payments.  Congress recently overrode Bush's veto of their bill to nullify this year's planned SGR reduction of 10% in provider payments.  There is another 40% reduction planned over the next several years.  Since all other costs go up annually, it is a no-brainer that annual reductions in Medicare fees will eventually result in providers ending their participation in the medicare program.

We are now at the Middle of the End.  Medicare now has this bounty hunter system using "recovery audit contractors", where auditors look for "overpayments" and errors.  There has been criticism, though, about inconsistent methods and a lack of oversight of the auditors.

But for physicians who come under the gaze of the contractors, the costs to the practice can be far more than the Medicare money at stake.

Marilou Terpenning, MD, a hematologist-oncologist in Santa Monica, Calif., had to respond to several rounds of medical record requests from PRG Schultz for claims involving alleged overpayment for chemotherapy. Some of the cited overpayments were as little as $13 or so per claim, but the cost to the practice of retrieving the corresponding record and forwarding the information could be 10 times that amount, she said.
I suspect that this is part of Medicare's death by a thousand cuts.  The hassle factor for dealing with Medicare will exponentially increase to the point that few participating providers will be left standing.

(It was raining all morning, so I decided to write a relevant post :-)

Wednesday, August 06, 2008

The Truman Show Delusion

Okay, so I'm not sure where to credit the idea for this post. I read about the Truman Show Delusion on The Last Psychiatrist blog, and it linked to a piece in the National Post.

The story starts by discussing a paper in process by two psychiatrists who are brothers-- that in itself is weird enough and maybe someday I'll know enough about it to blog about psychiatrist sibs (I only know of one family where this actually exists). The Gold shrink brothers are interested in a phenomena they've titled The Truman Show Delusion. It's when a patient believes he is a character in a reality TV show (when he isn't, obviously). From the National Post article:

While traditionalists insist that this delusion offers nothing new -- it is no different from, say, a deranged man who believes that the CIA has planted a microchip in his tooth -- the Gold brothers argue otherwise.

"It's really a question of the extent of the delusion," said Joel Gold, 39, who has been on staff at New York's Bellevue Hospital Center for eight years. "The delusions we typically treat are narrow: There is Capgras Delusion, where someone will think his family has been replaced by doubles. Or the Fregoli Delusion, where someone believes that one person is persecuting him: a doctor, mailman, butcher. The Truman Show Delusion, though, involves the entire world."

The Last Psychiatrist wants to discuss the delusion as a metaphor for maturity and fixation in adolescent developmental challenges. Okay.

I haven't examined the patients the Gold Shrink-bros write about, and I've never seen a patient with this particular delusional scheme, but in general, I've found that delusional schemes happen apart from personality characteristics and developmental fixations. In other words, I've seen patients with grandiose delusional schemes who aren't otherwise narcissistic in their overall approach to the world, and I know plenty of self-centered narcissistic folks who don't seem to have any type of delusional disorders. Oh, I'm rambling, I just thought the idea of a Truman Show Delusion was interesting.

And speaking of having one's life broadcast to the public eye: where oh where is Roy today?

Monday, August 04, 2008

Is My Techno-Life Making Me Crazy(-er)?

In case you haven't heard, Roy is on vacation. He's blogging us the day-to-day update, complete with photos and mishaps -- starting with the flat tire on Day #1. ClinkShrink is also on vacation. In fact, her vacation was inspired by Roy's photos from his vacation last year. Greetings to all from Baltimore where the remaining co-blogger.... remains.

Okay, so last week I had a 36 hour getaway to the beach where I was hosted by my good friend the Judge-in-Curlers. My three hour drive was punctuated by a text photo that ClinkShrink sent to my phone of her car packed for vacation (bikes on the back), and a lengthy discussion with my shrink friend, Camel. As I arrived at my destination, my cell phone battery died. Dead. Completely dead. Oh, and "bring phone charger" (I have three, plus one for the car that doesn't work) was the last thing on my packing list, and the one thing I forgot. Ugh! I felt anxious inside, borrowed a Blackberry to check my voicemail and call home, and I figured my first trip out in the morning would be to get a 4th charger.

The morning came and it was a lovely beach day. Breakfast, a walk on the boardwalk, and I suddenly realized I felt so much better with a dead phone. And no email access. This is what was meant by Zen. Whatever that means.... I checked my messages periodically with the borrowed Blackberry and reminded myself that no patient had ever called from a bridge ledge only to say they would have jumped had it not been for my brilliant and immediate intervention.

A break from technology-- I think it was a good thing. I often think it makes it hard for us ever to fully relax when the urge is there to glance at the phone, make sure there are no messages, hit the "inbox" button.

Okay, I confess, "I don't have a phone" was my first thought when I was rear-ended on the return trip (no injuries, no dents), but I came home vowing to take it easier on the technology. We'll see.

And just so you know, I've set Roy's new 3g iPhone so that it barks when I call.