Officials of the Southern California Permanente Medical Group (SCPMG) have decided to bring to a quick end their requirement that on the recommendation of psychologists or social workers psychiatrists have to prescribe medications for Kaiser Permanente HMO patients they have not evaluated.

The move follows a lawsuit against the physician group by a psychiatrist who was fired for refusing to comply with the practice and ethical concerns raised by psychiatrists in the San Diego area served by the Kaiser HMO. The prescribing policy also triggered an investigation by a California state agency that oversees professional and managed care issues.

In a May 3 press release—about three weeks after press coverage began to generate criticism from multiple sources, including APA—the medical group announced that it will now require all new patients in the HMO’s San Diego psychiatry department "to be examined by a physician before medication is prescribed."

The group’s medical director and board chair, Oliver Goldsmith, M.D., said that "changing our prescribing practices in San Diego will make it consistent with SCPMG practices in the rest of Southern California and will be responsive to the concerns that were raised."

Psychiatrists and others in the San Diego psychiatry department "evolved the team approach" to prescribing psychoactive drugs without Goldsmith’s knowledge, Jim Anderson, a Kaiser spokesperson told Psychiatric News. "Dr. Goldsmith learned about the practice through the media," said Anderson, and in response to the onslaught of critical publicity of the practice "started an evaluation of the situation and listened to the concerns" of physicians and others in San Diego and elsewhere. Goldsmith "concluded that this was a path we should turn back from," he said.

Patricia Siegel, R.N., the Kaiser Foundation Health Plan’s senior vice president for quality, regulatory, and member services, said in a press statement that the health plan asked the SCPMG to "examine" the prescribing situation in the San Diego psychiatry department and that the SCPMG "responded appropriately." She pointed out as well that Kaiser Foundation Health Plan, for whose subscribers the SCPMG physicians provide care, "has never had any policy or practice of requiring a psychiatrist to prescribe medicine without examining the patient," suggesting that the San Diego policy was an aberration.

Responding to the announcement from Kaiser Permanente, APA President-elect Daniel Borenstein, M.D., emphasized, "Decisions concerning appropriate use of medication as part of an overall treatment plan must be made by a psychiatrist drawing upon clinical information that can be acquired only through a face-to-face comprehensive evaluation of the patient and the patient’s overall medical and psychological status."

Borenstein went on to commend the Southern California Permanente Medical Group "for affirming the ethical traditions of medical practice."

The psychiatrist whose firing and subsequent lawsuit triggered much of the publicity about the HMO’s prescribing practices, Thomas Jensen, M.D., told Psychiatric News that he was "very pleased to hear that Kaiser is rethinking its [prescribing] policy." He added, however, that he is remaining "skeptical" until he learns more details about the changes than the medical group revealed in its press release.

Jensen said he is withholding judgment until he learns, for example, who will monitor that the policy has in fact been changed and how adherence to the new policy will be verified. He is also waiting to see whether the medical group will instruct psychiatrists to perform "appropriate assessments" or allow them to conduct very brief evaluations.

"Also, I still want to know," he added, "whether they will now do appropriate informed consent with patients" who are prescribed psychotropic drugs and what type of follow-up there will be of patients once they have taken these drugs for extended periods.

Jensen noted that since a press release announcing Kaiser’s intention to alter its prescribing policy in San Diego does not constitute a legal response, his lawsuit will remain active. "I wouldn’t drop a legal action just on the basis of a press release," he said.

Also still alive is the California Department of Corporations’ investigation into Kaiser’s prescribing practices. That state agency monitors how HMOs, other managed care organizations, and health care providers comply with state laws and regulations governing their operation.

In addition, in a letter to legal counsel for the Department of Corporations’ Health Plan Enforcement Division, the Medical Board of California expressed its concerns about possible "unprofessional conduct" and how involved nonphysician therapists who lack prescription privileges may have been in prescribing medications for patients.

Anderson, the Kaiser spokesperson, indicated that 22 psychiatrists were employed in the organization’s San Diego area HMOs while the prescribing policy was in effect.—K.H.