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By David E. Drake, D.O.
Why, some ask, would any self-respecting psychiatrist and APA member consider working as a managed care reviewer?
Over the last eight months, I have served as a psychiatric peer reviewer for the corporation that manages mental health benefits for Iowa's Medicaid population. I spend a half day each week in this capacity, reviewing lengths of stay in hospital settings, both retrospectively and for current inpatient stays.
As chair of the Iowa Psychiatric Society Ethics Committee, I wanted to become familiar with what many see as the new frontier of ethical issues in our profession. I also have to admit that I enjoy working and living "on the edge"-throwing myself into controversial areas and trying to achieve some personal clarity about how I think and relate to the issue at hand.
At the very beginning, I informed the medical director that I would remain in this new role as long as I was comfortable with the work requirements and as long as he wanted me to stay on.
I voiced my objections to certain procedures early on. These have included the request by front-line "care managers" (that is, psychiatric nurses) for me to provide unsolicited telephone "consultations" to psychiatrists attending a particular patient in the hospital. I objected to this practice on the grounds that it strikes me as intrusive and assumes I have a better handle on how to treat a particular patient than the attending, even though I have never seen the patient. I would consider fulfilling their request only if after I reviewed the records, the treatment seemed totally out of range for reasonable psychiatric treatment.
As I work only five hours a week with this particular company, I do not depend on the work for my income. I do have concerns about reviewers who become financially dependent on the managed care company, as one's allegiance can easily become swayed by the money and by relationships within the company. Who wants to cause annoyance or displeasure among one's coworkers by making decisions that are contrary to what is recommended? I have learned to accept occasional rolling of my coworkers' eyeballs in response to some of my decisions.
In addition, I have serious concerns about the practice of this and other managed care companies to contract with out-of-state psychiatric reviewers. They are not held accountable to our own state board of medical examiners for their decisions about a patient's care. And, indeed, the director of our own board has informed me that she views managed care peer review work as practicing medicine-with all the responsibilities to patients therein.
I have flexibility in my work, and I take advantage of it. I view the company's admission and continued-stay guidelines as only part of the decision-making process. I place myself in the position of the attending psychiatrist and make my decisions partly on the basis of how I would respond to the same clinical situation. Of course, many gray areas exist. I choose to err on the side of the patient and the psychiatrist whenever possible. When I perform telephone reviews with attending psychiatrists, I often start out by asking for reasons to extend the length of stay. I am looking to become persuaded and give them the opportunity to do so. Obviously, practice styles and theoretical assumptions in our broad profession vary.
I do not review hospitals in the Des Moines area, where I practice, nor have I reviewed cases of psychiatrists I know. This appears standard practice, and I imagine it has mostly to do with not wanting to anger one's local colleagues. I recently sat down to lunch at our most recent Iowa Psychiatric Society meeting and was told by a colleague I had just met that I had reviewed one of his cases for a "doc-to-doc" review. I asked him how I had done. He replied, "You were very collegial." I was pleased that he had experienced my review time with him in that manner.
On the other side of the coin, many psychiatric hospital medical records do not contain adequate information to help support continued inpatient stays. Either the psychiatrists are so angry at having their work overseen or they may assume that their particular county will pick up the bill-which is true in some cases.
I give slack where I can, but rarely in cases where the attending psychiatrist hasn't provided information to at least attempt to support the need for a patient's continued hospitalization.
I hope that more APA members consider part-time work as peer reviewers. I believe psychiatrists can have an impact on how managed care companies operate. We owe it to our hospitals, patients, and our colleagues across this nation.
Dr. Drake is a family psychiatrist and an associate professor of psychiatry at the University of Osteopathic Medicine and Health Sciences in Des Moines.