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Dr. Charles Atkins, in "Physician Reviewers Not the Answer" in the May 15 Viewpoints column, reiterates what others have said, namely that there are problems in the process used by managed care to review cases and certify reimbursement.
He writes: "[P]hysicians are being paid to deny and limit treatment." In the spirit of Dr. Atkins's call for "a real need to work to correct the problems with this system," I strongly suggest it is more accurate and real to say physician advisers are now being paid to identify cases where the quality of care is questionable and patients are exposed to unnecessary risks.
Patients, providers, purchasers, and managed care companies share common goals in their desire to receive, provide, purchase, and deliver quality mental health care at cost-effective prices. However, quality is not equal across all physicians and hospitals, partial programs, residential treatment centers, outpatient clinics, and professional offices. Reductions in variation is perhaps the most important critical matter in improving quality. Physician-to-physician reviews are one kind of golden opportunity to address this physician imperative to improve the quality of care and reduce the variations.
It seems to me the value of the reviews can be increased if psychiatric providers and managed care physician reviewers use the time they spend together reviewing cases to pay close attention to whether patients are receiving quality care. Psychiatrists on both sides of the telephone line ought to be engaged in discussing whether: the treatment is based on sound clinical data and information, reliably and efficiently obtained; the interventions utilized are scientifically supported by providers reasoning together to decide that the treatment is useful for patients with similar illness characteristics; and the process of care delivered is increasing the probability of desired patient outcomes.
Basil G. Bernstein, M.D.
Philadelphia, Pa.
Dear Dr. Atkins:
I read with great interest your Viewpoints column in the May 15 issue. Your tolerant, evenhanded, patient attempt to present with fairness your interactions during a case review with a medical director of a psychiatric carveout company. The psychiatrist doing the review was previously a respectable clinician, now putting his corporate loyalties before the needs of a psychiatrically ill older woman and encouraging you to cheat her out of needed care.
It appeared to be a case in which the medical director of the carveout was encouraging you in frank malpractice, backing his unethical treatment recommendations with the full financial leverage and power of his position.
Like many of us when faced with this type of rather startling invitation by a managed care organization (MCO) to taint our medical ethics (coupled with financial blackmail by the MCO), your Psychiatric News essay shows a tendency to deny or minimize the fundamental, irrational crassness of the situation and to attempt some rational response to or analysis of it.
My take on this all-too-common situation is that the medical director, a fellow psychiatrist, is directing you (with reinforcement of his message by withholding payment for the patient's care) to violate a serious ethical boundary and shortchange the patient's treatment. He should be no less accountable for his directive, nor should his directive be perceived as any less unethical because of the fact that you do the right thing and don't follow his direction.
As a physician in a position of power and influence, he is abusing a fiduciary and ethical responsibility to patients and to the professionals that treat them. I would suggest that in this type of situation a psychiatrist ought to consider filing a formal ethical complaint about the actions of such MCO medical directors with the ethics committees of the local psychiatric association and medical association and with the state board of registration in medicine, while undertaking a concerted campaign to gain the support of the relevant professional associations. Intentional or not, this type of action by an MCO medical director promulgates frank ethical malpractice throughout a system of care and ends up involving many "providers."
Medical directors of MCOs need to be as accountable ethically as any other clinician and must not treated as if they were a special breed outside of or above the law. We should not cease to have our eyes open to the ethical violations in this type of situation. We should not tolerate the violations, and we should not fail to use whatever legitimate actions are available to us in this egregious type of situation.
An ethical complaint filed in response to every action by MCO medical directors of the type that you describe might have a sobering corrective effect on the doctors in these positions who "sell their birthright for a mess of pottage."
Jerome A. Collins, M.D.
Chair
Managed Care Committee
Maine Psychiatric Association