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Why Don’t Psychiatrists Like To Show Patients Their Notes?

Please see my post on Clinical Psychiatry News and yesterday’s post What’s in a Note? along with the reader comments.

One reader asked why it’s weird to want to see your shrink’s notes and why shrinks refuse to show them on the grounds that they may distress the patients.  Another reader asked why doctors write “patient denies” as though they don’t believe the patient.  These are both great questions worthy of their own post.

Why don’t psychiatrists like to show patients their notes?  Are they really going to “harm” the patient?  There are a few reasons why a psychiatrist may not want to show a patient her notes.  Here is my list of thoughts as bullet points. Please feel free to add to it. Read more »

*This blog post was originally published at Shrink Rap*

Dr. Steve Novella Defends Science And Reason On The Dr. Oz Show

I must say I was a bit shocked two weeks ago when I was contacted by a producer for The Dr. Oz Show inviting me on to discuss alternative medicine. We have been quite critical of Dr. Mehmet Oz over his promotion of dubious medical treatments and practitioners, and I wondered if they were aware of the extent of our criticism (they were, it turns out).

Despite the many cautions I received from friends and colleagues (along with support as well) – I am always willing to engage those with whom I disagree. I knew it was a risk going into a forum completely controlled by someone who does not appear to look kindly upon my point of view, but a risk worth taking. I could only hope I was given the opportunity to make my case (and that it would survive the editing process).

The Process

Of course, everyone was extremely friendly throughout the entire process, including Dr. Oz himself (of that I never had any doubt). The taping itself went reasonably well. I was given what seemed a good opportunity to make my points. However, Dr. Oz did reserve for himself the privilege of getting in the last word—including a rather long finale, to which I had no opportunity to respond. Fine—it’s his show, and I knew what I was getting into. It would have been classy for him to give an adversarial guest the last word, or at least an opportunity to respond, but I can’t say I expected it. Read more »

*This blog post was originally published at Science-Based Medicine*

Physicians’ Anemic Response To Healthcare Reform: Passivity Or Denial

With the turn of the calendar to the new decade, the reality of health care reform has set in for doctors and patients. Already cuts to physician salaries and patient access to care are becoming starkly apparent to those of us on the front lines of health care.

I wonder why doctors have been so ineffectual relative to the other special interests “at the table,” in the health care debate? One would think that those with the knowledge base and skill to manage their patients would be the ultimate power brokers in the efforts of health care reform. Yet here we are, watching the commoditization of our profession at the hands of lawyers and politicians in Washington, eager to avoid being perceived as the spoiler. Read more »

*This blog post was originally published at Dr. Wes*

Pharmacists Face Consumer Rage Over Insurance Denials

I was at the pharmacy today picking up some goods.  We indicated to the pharmacy tech our cash paying status.  The nice lady behind the counter explained that the drug company had a discount plan for cash paying customers that do not submit a claim to their insurance company.  We had to promise not to submit the claim and not to sell the medication on the internet for which we obliged.  Then we had a seat and waited.

In the next 30 minutes I had the opportunity to listen to several customers blow up in a fit of rage about why their insurance company wasn’t covering this or that.  Read more »

*This blog post was originally published at A Happy Hospitalist*

The Problem With Health Insurance

Something touched a nerve yesterday.  I kind of lost my composure when someone tried to defend the insurance industry and responded out of emotion – perhaps putting aside some reason in the process.

I used to get mad at myself or embarrassed when this happened, but now I stand back and try to analyze my reaction.  What is it that touched a nerve in me?  Why did I feel so strongly?  We don’t feel things without reason, and my reaction doesn’t necessarily betray weakness on my part, it shows the depths of my emotion.  That passion usually comes from something – most of the time it is personal experience; and my personal experience says that insurance companies are causing my patients harm.  That makes me angry.

I don’t think the people in the insurance industry are bad people.  I think vilifying people is the easy way out.  The people there feel like they are doing the right thing, and are no less moral than me.  But I do not think the way to fix our system is through letting them do their business as usual in the name of “free market.”  Defending the current system of insurance ignores some obvious problems in our system:

1.  They are financially motivated to withhold services

If you hire a contractor to work on your house, how wise is it to pay them 100% in advance?  You have just given them financial incentive to do as little work as possible, as it will maximize their profits to do so.  The insurance industry is in such a situation; despite any good intention, they are put in a position to decide between profits and level of service.  It is much better to pay more for better service, not worse; but that is what we have done with health insurance companies.

2.  They have been given the ability to withhold services

If all United Health Care (for example) did was to provide insurance, they would not be vilified as they are.  But since the only data available for medical care was the claims data they hold, they were put in a position to control cost.  This was sensible initially, as they had both the data and the means (denying unnecessary care) of cutting cost.  It’s OK that women aren’t kept in the hospital for a week after having a baby.  It’s OK that I can’t prescribe expensive brand-name drugs when there is a reasonable generic alternative.  There was a whole lot of fat to cut, and they did a good job cutting that fat.

The problem came when all the fat was gone and they were used to big profit-margins.  Once there was not any more unnecessary care to cut, they had two ways to keep their profit-margins: increasing premiums or cutting services.  They did both.  Both of these have hurt my patients.

  • Patients have had premiums increased or have been dropped because they were diagnosed with medical problems.  I have had patients beg me “don’t put that in my record,” as they know a diagnosis of diabetes or heart disease will be disastrous.  I am then caught between the pleas of my patients and the demands of honestly practicing and documenting my care.
  • I do what I can to follow evidence-based standards, but there are times when people fall out of the norms.  Medicine is not science, it is applied science.  This means that I am trying to take an individual and somehow match them with the scientific data.  Sometimes it works, but everyone is different.  If something is true 90% of the time, 10% of the people will be exceptions to the rule.  I have repeatedly been told by “gnomes” (people with minimal medical education who sit in front of a computer screen with a protocol for care) what “good medicine” looks like.  They see things as black and white when it is just not that way.  This has caused people to be unnecessarily hospitalized, it has required them to get unnecessary tests to follow their rules.  There is no arguing with people in front of computers.

3.  They covertly ration

Dr. Rich Fogoros (whom I recently met) has coined this phrase to explain what happens in our system.  Because it doesn’t look good to deny necessary care, insurance companies (including government-run ones) resort to making things exceedingly complex.  This makes it look like care is being offered, but not taken advantage of.    What does this mean?

  • The burden of proof is put on the provider to show the tests ordered are necessary.  The assumption is that a test will be denied unless the doc can prove otherwise.
  • Tests are sometimes inappropriately denied.  They then can be appealed, but the appeal process is even more difficult than the initial approval process, and so some people give up.  Every time someone gives up, less is paid out by the insurance company and their profits go up.
  • The rules for coding and billing are so complex, that it is very easy to make mistakes.  This means that an appropriate test ordered by a doctor that is not perfectly coded doesn’t get paid for.  The patient gets the bill and must get the doctor to appeal the denial.  This appeal process, again, is difficult.

Because of this, I have to hire staff whose sole task is to learn all of the rules of the different insurance carriers (including public ones) and then play the game properly with them so that we get as few denials as possible.  I probably spend $70-80 thousand per year to deal with the frustratingly complex system we have.

————

I have health insurance.  I do understand why it needs to exist, but I also see how harmful the current state can be to my patients.  I get frustrated with Medicare and Medicaid as well, but that is not my point.  Just because government run insurance has problems doesn’t do anything to change the problems with private insurance.  The fact that you can be killed by firing squad doesn’t make the gallows any better.

The cost of care has gone up dramatically over the past 10 years while my reimbursement has dropped.  Where is that extra money?

But the system is very broken right now.  It needs to be fixed.  Things need to be changed in both the private and public sector.  When I was in DC I made the point that our ship is sinking and we are arguing about who will be the captain.  The problems in our system are not simply who is writing the checks.

Honestly, I don’t really care who writes the checks.  All I want is for the system to reward good care and to stop hurting my patients.  Those who deny the reality of either of these problems will invariably draw my ire.

*This blog post was originally published at Musings of a Distractible Mind*

Latest Interviews

IDEA Labs: Medical Students Take The Lead In Healthcare Innovation

It’s no secret that doctors are disappointed with the way that the U.S. healthcare system is evolving. Most feel helpless about improving their work conditions or solving technical problems in patient care. Fortunately one young medical student was undeterred by the mountain of disappointment carried by his senior clinician mentors…

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How To Be A Successful Patient: Young Doctors Offer Some Advice

I am proud to be a part of the American Resident Project an initiative that promotes the writing of medical students residents and new physicians as they explore ideas for transforming American health care delivery. I recently had the opportunity to interview three of the writing fellows about how to…

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Latest Book Reviews

Book Review: Is Empathy Learned By Faking It Till It’s Real?

I m often asked to do book reviews on my blog and I rarely agree to them. This is because it takes me a long time to read a book and then if I don t enjoy it I figure the author would rather me remain silent than publish my…

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The Spirit Of The Place: Samuel Shem’s New Book May Depress You

When I was in medical school I read Samuel Shem s House Of God as a right of passage. At the time I found it to be a cynical yet eerily accurate portrayal of the underbelly of academic medicine. I gained comfort from its gallows humor and it made me…

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Eat To Save Your Life: Another Half-True Diet Book

I am hesitant to review diet books because they are so often a tangled mess of fact and fiction. Teasing out their truth from falsehood is about as exhausting as delousing a long-haired elementary school student. However after being approached by the authors’ PR agency with the promise of a…

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