Shrink Rap News

I’m getting tired of being blamed for the death of my profession.

My clinical practice in prison consists almost entirely of diagnostic assessments and medication management. While I do a small amount of therapy, this is usually limited to occasional crisis intervention and brief supportive counseling in the context of an intake assessment.

Fortunately, over the past 20 years, I have worked with a series of skilled and qualified psychologists, and we work very closely together. They provide cognitive therapy, anger management therapy, bereavement counseling, sex offender therapy, and a host of other services.

I step in when they need help sorting out a diagnosis, when medical conditions appear to be affecting a patient’s mental status, or when there are policy issues that demand only the intervention of a medical doctor. It’s a model that’s worked well for me and my patients. And because I’ve been at the facility a long time, I’ve gotten to know our regular patients due to their repeated incarcerations.

For many prisoners, this is the only system of mental health care they have ever known. And because the average incarceration for a felony in my state lasts 2 or 3 years, I have a wealth of previous clinical data I can refer to when needed. I am able to pace my practice at a comfortable level, and I see only the number of patients I feel I can reasonably handle in a day. I am not paid based upon the number of patients I see or how fast I “churn” them.

Nevertheless, my colleagues vent – both online and in person – about increasing numbers of psychiatrists who have med-check only practices and about the commercial forces driving this change. They fear that psychiatry training programs are placing less emphasis on teaching psychotherapy, and that leaving this treatment modality to other professionals is an abdication of care and a blow to our professional standards. Doctors with med-check only practices are vilified as being greedy or therapeutically inept, having poor social skills and always as doctors who give suboptimal care.

Sometimes I get special dispensation because I work in a prison. After all, they reason, it’s a prison – we all know that prisons are going to provide suboptimal care (if they receive any care at all), and who cares if that pedophile gets to see a psychiatrist, anyway? They’re just criminals.

Ah, it gets old.

The need to listen to one’s patients is not limited to psychiatry, and neither are the financial concerns that may lead a doctor to offer certain treatment modalities over others. If psychiatrists are pressured to increase their caseloads because of financial concerns, so are internists, family practitioners, and surgeons. And if failure to provide therapy is such a danger to the profession, perhaps we also should vilify those who choose to become basic science researchers, administrators, and non-practicing academicians?

The future of psychiatry, and medicine in general, will depend upon our ability to work with other professionals and to recognize the unique skills that each bring to the table (or bedside). The “medical home” model for psychiatry requires coordination of care between primary care physicians, psychiatrists, psychologists, social workers, and others. In this model, psychiatrists are likely to provide medication management services alone or with a non-psychiatrist therapist. The medical home model has been shown to improve general health outcomes and reduce hospitalizations for psychiatric patients in free society.

This model also has recently been shown to improve engagement with community health services for newly released prisoners and to cut reincarceration rates for mentally ill prisoners by up to 71%.  Given these facts, we may have to admit that what isn’t “good” for our profession may be better for our patients.

—Annette Hanson

DR. HANSON is a forensic psychiatrist and co-author of Shrink Rap: Three Psychiatrists Explain Their Work. The opinions expressed are those of the author only, and do not represent those of any of Dr. Hanson’s employers or consultees, including the Maryland Department of Health and Mental Hygiene or the Maryland Division of Correction.

I’m getting tired of being blamed for the death of my profession.

My clinical practice in prison consists almost entirely of diagnostic assessments and medication management. While I do a small amount of therapy, this is usually limited to occasional crisis intervention and brief supportive counseling in the context of an intake assessment.

Fortunately, over the past 20 years, I have worked with a series of skilled and qualified psychologists, and we work very closely together. They provide cognitive therapy, anger management therapy, bereavement counseling, sex offender therapy, and a host of other services.

I step in when they need help sorting out a diagnosis, when medical conditions appear to be affecting a patient’s mental status, or when there are policy issues that demand only the intervention of a medical doctor. It’s a model that’s worked well for me and my patients. And because I’ve been at the facility a long time, I’ve gotten to know our regular patients due to their repeated incarcerations.

For many prisoners, this is the only system of mental health care they have ever known. And because the average incarceration for a felony in my state lasts 2 or 3 years, I have a wealth of previous clinical data I can refer to when needed. I am able to pace my practice at a comfortable level, and I see only the number of patients I feel I can reasonably handle in a day. I am not paid based upon the number of patients I see or how fast I “churn” them.

Nevertheless, my colleagues vent – both online and in person – about increasing numbers of psychiatrists who have med-check only practices and about the commercial forces driving this change. They fear that psychiatry training programs are placing less emphasis on teaching psychotherapy, and that leaving this treatment modality to other professionals is an abdication of care and a blow to our professional standards. Doctors with med-check only practices are vilified as being greedy or therapeutically inept, having poor social skills and always as doctors who give suboptimal care.

Sometimes I get special dispensation because I work in a prison. After all, they reason, it’s a prison – we all know that prisons are going to provide suboptimal care (if they receive any care at all), and who cares if that pedophile gets to see a psychiatrist, anyway? They’re just criminals.

Ah, it gets old.

The need to listen to one’s patients is not limited to psychiatry, and neither are the financial concerns that may lead a doctor to offer certain treatment modalities over others. If psychiatrists are pressured to increase their caseloads because of financial concerns, so are internists, family practitioners, and surgeons. And if failure to provide therapy is such a danger to the profession, perhaps we also should vilify those who choose to become basic science researchers, administrators, and non-practicing academicians?

The future of psychiatry, and medicine in general, will depend upon our ability to work with other professionals and to recognize the unique skills that each bring to the table (or bedside). The “medical home” model for psychiatry requires coordination of care between primary care physicians, psychiatrists, psychologists, social workers, and others. In this model, psychiatrists are likely to provide medication management services alone or with a non-psychiatrist therapist. The medical home model has been shown to improve general health outcomes and reduce hospitalizations for psychiatric patients in free society.

This model also has recently been shown to improve engagement with community health services for newly released prisoners and to cut reincarceration rates for mentally ill prisoners by up to 71%.  Given these facts, we may have to admit that what isn’t “good” for our profession may be better for our patients.

—Annette Hanson

DR. HANSON is a forensic psychiatrist and co-author of Shrink Rap: Three Psychiatrists Explain Their Work. The opinions expressed are those of the author only, and do not represent those of any of Dr. Hanson’s employers or consultees, including the Maryland Department of Health and Mental Hygiene or the Maryland Division of Correction.

I’m getting tired of being blamed for the death of my profession.

My clinical practice in prison consists almost entirely of diagnostic assessments and medication management. While I do a small amount of therapy, this is usually limited to occasional crisis intervention and brief supportive counseling in the context of an intake assessment.

Fortunately, over the past 20 years, I have worked with a series of skilled and qualified psychologists, and we work very closely together. They provide cognitive therapy, anger management therapy, bereavement counseling, sex offender therapy, and a host of other services.

I step in when they need help sorting out a diagnosis, when medical conditions appear to be affecting a patient’s mental status, or when there are policy issues that demand only the intervention of a medical doctor. It’s a model that’s worked well for me and my patients. And because I’ve been at the facility a long time, I’ve gotten to know our regular patients due to their repeated incarcerations.

For many prisoners, this is the only system of mental health care they have ever known. And because the average incarceration for a felony in my state lasts 2 or 3 years, I have a wealth of previous clinical data I can refer to when needed. I am able to pace my practice at a comfortable level, and I see only the number of patients I feel I can reasonably handle in a day. I am not paid based upon the number of patients I see or how fast I “churn” them.

Nevertheless, my colleagues vent – both online and in person – about increasing numbers of psychiatrists who have med-check only practices and about the commercial forces driving this change. They fear that psychiatry training programs are placing less emphasis on teaching psychotherapy, and that leaving this treatment modality to other professionals is an abdication of care and a blow to our professional standards. Doctors with med-check only practices are vilified as being greedy or therapeutically inept, having poor social skills and always as doctors who give suboptimal care.

Sometimes I get special dispensation because I work in a prison. After all, they reason, it’s a prison – we all know that prisons are going to provide suboptimal care (if they receive any care at all), and who cares if that pedophile gets to see a psychiatrist, anyway? They’re just criminals.

Ah, it gets old.

The need to listen to one’s patients is not limited to psychiatry, and neither are the financial concerns that may lead a doctor to offer certain treatment modalities over others. If psychiatrists are pressured to increase their caseloads because of financial concerns, so are internists, family practitioners, and surgeons. And if failure to provide therapy is such a danger to the profession, perhaps we also should vilify those who choose to become basic science researchers, administrators, and non-practicing academicians?

The future of psychiatry, and medicine in general, will depend upon our ability to work with other professionals and to recognize the unique skills that each bring to the table (or bedside). The “medical home” model for psychiatry requires coordination of care between primary care physicians, psychiatrists, psychologists, social workers, and others. In this model, psychiatrists are likely to provide medication management services alone or with a non-psychiatrist therapist. The medical home model has been shown to improve general health outcomes and reduce hospitalizations for psychiatric patients in free society.

This model also has recently been shown to improve engagement with community health services for newly released prisoners and to cut reincarceration rates for mentally ill prisoners by up to 71%.  Given these facts, we may have to admit that what isn’t “good” for our profession may be better for our patients.

—Annette Hanson

DR. HANSON is a forensic psychiatrist and co-author of Shrink Rap: Three Psychiatrists Explain Their Work. The opinions expressed are those of the author only, and do not represent those of any of Dr. Hanson’s employers or consultees, including the Maryland Department of Health and Mental Hygiene or the Maryland Division of Correction.

I was talking with a friend the other day. I’ve known him for at least a decade, and years ago, he told me that he takes Paxil. It’s not something he’s brought up in a long time, but over the weekend, unrelated to the topic we were discussing, he suddenly said, “This med check thing is quite the racket psychiatrists have going.” He sees his psychiatrist for 15 minutes every 6 months.

“The question is always the same. He asks me, ‘On a scale of 1 to 10, rate your mood.’  I answer, but you know, in 6 hours I might have a different answer.”

I didn’t ask what the med check sessions cost, or why he doesn’t get his prescription from his primary care doctor, but I can’t imagine that the psychiatrist is making any great fortune from the two visits per year my friend (or his insurance company) pays for.

But he’s also my second friend in a matter of months who has commented to me how his brief checklist visits with a psychiatrist feel like they are more about the doc making a buck than about the well-being of the patient. The other friend saw a psychiatrist for a monthly med check to obtain a stimulant prescription at a cost of $120/visit and quickly calculated that the psychiatrist was earning $360 an hour. Is that too much or too little, or does that even matter? What does matter is that there are no warm or fuzzy feelings here.

I don’t believe that every patient needs, wants, or benefits from psychotherapy, but I do believe that treatment should be tailored to the patient – so while weekly therapy with a psychiatrist may make sense for some people and 15-minute visits twice a year may make sense for others, there isn’t a template that leaves everyone with the best care. Somehow, the insurance industry decided that reimbursement would be more lucrative for brief visits.

This translated into a paradigm where management of a psychiatric conditions could be done in 15- or 20-minute blocks, and a treatment model developed where psychiatrists limit interactions to a checklist of symptoms and side effects. Obviously, I’m not telling you anything you don’t know.  

The economics may be clear, but what gets washed out is how much some patients dislike and disdain their psychiatrists and the negative backlash psychiatry has suffered in terms of the image the public has of our work. If you’re not sure about this, just look at the comment section of the online version of any article about mental health in the New York Times.

Some people feel that psychiatry is about checklists and prescriptions pads – psychiatrists are “pill pushers” (they don’t just suggest, they push), and they are angry that their doctors don’t know them, don’t care to know them, and aren’t interested in understanding their symptoms in the full context of their lives.

One of the troubling aspects of this approach to care is that even when the treatment is successful and the patients get better (as in the case of both of my friends above), they may well walk away angry or ungrateful. As much as people want to get better, they also want to feel heard.  

So is it a racket? I don’t know that anyone’s motives are bad – as a “racket” might imply – and it’s clearly not the model that all (or even most) psychiatrists practice by, but for some patients, this approach to treatment is misguided, and it’s unfortunate for all of us that is the image of psychiatry that the public has come to see.

—Dinah Miller

If you would like to check out our main Shrink Rap blog, please click here.   

DR. MILLER is the co-author of Shrink Rap: Three Psychiatrists Explain Their Work, published by Johns Hopkins University Press.

I was talking with a friend the other day. I’ve known him for at least a decade, and years ago, he told me that he takes Paxil. It’s not something he’s brought up in a long time, but over the weekend, unrelated to the topic we were discussing, he suddenly said, “This med check thing is quite the racket psychiatrists have going.” He sees his psychiatrist for 15 minutes every 6 months.

“The question is always the same. He asks me, ‘On a scale of 1 to 10, rate your mood.’  I answer, but you know, in 6 hours I might have a different answer.”

I didn’t ask what the med check sessions cost, or why he doesn’t get his prescription from his primary care doctor, but I can’t imagine that the psychiatrist is making any great fortune from the two visits per year my friend (or his insurance company) pays for.

But he’s also my second friend in a matter of months who has commented to me how his brief checklist visits with a psychiatrist feel like they are more about the doc making a buck than about the well-being of the patient. The other friend saw a psychiatrist for a monthly med check to obtain a stimulant prescription at a cost of $120/visit and quickly calculated that the psychiatrist was earning $360 an hour. Is that too much or too little, or does that even matter? What does matter is that there are no warm or fuzzy feelings here.

I don’t believe that every patient needs, wants, or benefits from psychotherapy, but I do believe that treatment should be tailored to the patient – so while weekly therapy with a psychiatrist may make sense for some people and 15-minute visits twice a year may make sense for others, there isn’t a template that leaves everyone with the best care. Somehow, the insurance industry decided that reimbursement would be more lucrative for brief visits.

This translated into a paradigm where management of a psychiatric conditions could be done in 15- or 20-minute blocks, and a treatment model developed where psychiatrists limit interactions to a checklist of symptoms and side effects. Obviously, I’m not telling you anything you don’t know.  

The economics may be clear, but what gets washed out is how much some patients dislike and disdain their psychiatrists and the negative backlash psychiatry has suffered in terms of the image the public has of our work. If you’re not sure about this, just look at the comment section of the online version of any article about mental health in the New York Times.

Some people feel that psychiatry is about checklists and prescriptions pads – psychiatrists are “pill pushers” (they don’t just suggest, they push), and they are angry that their doctors don’t know them, don’t care to know them, and aren’t interested in understanding their symptoms in the full context of their lives.

One of the troubling aspects of this approach to care is that even when the treatment is successful and the patients get better (as in the case of both of my friends above), they may well walk away angry or ungrateful. As much as people want to get better, they also want to feel heard.  

So is it a racket? I don’t know that anyone’s motives are bad – as a “racket” might imply – and it’s clearly not the model that all (or even most) psychiatrists practice by, but for some patients, this approach to treatment is misguided, and it’s unfortunate for all of us that is the image of psychiatry that the public has come to see.

—Dinah Miller

If you would like to check out our main Shrink Rap blog, please click here.   

DR. MILLER is the co-author of Shrink Rap: Three Psychiatrists Explain Their Work, published by Johns Hopkins University Press.

I was talking with a friend the other day. I’ve known him for at least a decade, and years ago, he told me that he takes Paxil. It’s not something he’s brought up in a long time, but over the weekend, unrelated to the topic we were discussing, he suddenly said, “This med check thing is quite the racket psychiatrists have going.” He sees his psychiatrist for 15 minutes every 6 months.

“The question is always the same. He asks me, ‘On a scale of 1 to 10, rate your mood.’  I answer, but you know, in 6 hours I might have a different answer.”

I didn’t ask what the med check sessions cost, or why he doesn’t get his prescription from his primary care doctor, but I can’t imagine that the psychiatrist is making any great fortune from the two visits per year my friend (or his insurance company) pays for.

But he’s also my second friend in a matter of months who has commented to me how his brief checklist visits with a psychiatrist feel like they are more about the doc making a buck than about the well-being of the patient. The other friend saw a psychiatrist for a monthly med check to obtain a stimulant prescription at a cost of $120/visit and quickly calculated that the psychiatrist was earning $360 an hour. Is that too much or too little, or does that even matter? What does matter is that there are no warm or fuzzy feelings here.

I don’t believe that every patient needs, wants, or benefits from psychotherapy, but I do believe that treatment should be tailored to the patient – so while weekly therapy with a psychiatrist may make sense for some people and 15-minute visits twice a year may make sense for others, there isn’t a template that leaves everyone with the best care. Somehow, the insurance industry decided that reimbursement would be more lucrative for brief visits.

This translated into a paradigm where management of a psychiatric conditions could be done in 15- or 20-minute blocks, and a treatment model developed where psychiatrists limit interactions to a checklist of symptoms and side effects. Obviously, I’m not telling you anything you don’t know.  

The economics may be clear, but what gets washed out is how much some patients dislike and disdain their psychiatrists and the negative backlash psychiatry has suffered in terms of the image the public has of our work. If you’re not sure about this, just look at the comment section of the online version of any article about mental health in the New York Times.

Some people feel that psychiatry is about checklists and prescriptions pads – psychiatrists are “pill pushers” (they don’t just suggest, they push), and they are angry that their doctors don’t know them, don’t care to know them, and aren’t interested in understanding their symptoms in the full context of their lives.

One of the troubling aspects of this approach to care is that even when the treatment is successful and the patients get better (as in the case of both of my friends above), they may well walk away angry or ungrateful. As much as people want to get better, they also want to feel heard.  

So is it a racket? I don’t know that anyone’s motives are bad – as a “racket” might imply – and it’s clearly not the model that all (or even most) psychiatrists practice by, but for some patients, this approach to treatment is misguided, and it’s unfortunate for all of us that is the image of psychiatry that the public has come to see.

—Dinah Miller

If you would like to check out our main Shrink Rap blog, please click here.   

DR. MILLER is the co-author of Shrink Rap: Three Psychiatrists Explain Their Work, published by Johns Hopkins University Press.

I was invited to testify at a congressional forum last week by Congressman Chris Van Hollen about challenges in the implementation and enforcement of the Mental Health Parity and Addiction Equity Act (MHPAEA). Also present were Congressmen Jim Moran and Paul Tonko, and former Congressmen Patrick Kennedy and Jim Ramstad.  These dedicated representatives stayed past 9 p.m., reflecting their dedication and resolve to ensure that the Parity Act be fully implemented.

As most readers of Clinical Psychiatry News are aware, people with mental health and addiction problems have long been stigmatized and marginalized in the health care system, and this one action – passing the 2008 Parity Act – will prove to be a historic correction of this great wrong. Indeed, the first attempt to correct the discriminatory practices of the health insurance industry was passed in 1996, but the industry figured out how to get around the intent of that first Parity Act. The ongoing efforts to close these loopholes are currently stuck, with the lack of final regulations that would dictate to payers how MHPAEA will be implemented and enforced, despite the law being passed 4 years ago.

Even URAC, the standards-based accreditation organization that accredits health insurance plans, has beat the federal government by recently updating its standards to require health plans to clearly and effectively demonstrate compliance with the Parity Act. To my knowledge, this is the first organization to specifically build Parity Act compliance into its standards for accreditation.

There has been an interim final rule passed, but such temporary regulations lack the finality that makes health plans address the more challenging aspects of compliance, particularly the nonquantitative treatment limits, or NQTLs. One of the more pervasive, yet hidden, NQTLs is the inadequacy of behavioral health provider networks compared to that of primary care networks.

I believe that network adequacy is probably THE biggest barrier to accessing care for our patients. When I ask patients about any problems finding a primary care physician, they rarely have problems. But finding an in-network psychiatrist has become an overwhelming problem. The insurance plans do not maintain a large enough network of physicians who specialize in psychiatry, creating a bottleneck that makes it hard for patients to initiate treatment.

While there has been some reductions in the need to obtain prior authorizations for outpatient treatment, the loophole here is that if there are not enough psychiatrists in the network who can actually see the patients needing care, many patients go without. This effectively limits the number of claims a payer must pay out. This is a nonquantitative treatment limit that is more restrictive on the mental health and addictions side than on the physical health side.

You’d think that one could determine the adequacy of the network by the number of providers in it, but this number is not an accurate reflection of the true size of the network. Look more closely and you discover a number of tricks that inflate the apparent size of the network. Whether these “tricks” are intentional or not, they amount to – in my opinion – fraud. If you pay for a plan that has 40 doctors listed in its online provider directory, you expect that you can see most of these 40 doctors. If the truth was that there are only four who could actually see you, then this is false advertising. It is a form of treatment limitation that seems to be applied particularly to behavioral health much more than to primary care.

Here are five of the most common tricks used:

1. Mixing provider types in the directory, with no way to select out just one type. There may be 40 providers within 10 miles of your Zip code, but the psychologists, social workers, psychiatrists, psychiatric nurses, and counselors are all mixed in together, even though they each have different scopes of practice. This inflates the apparent size of the true network when only 6 of the 40 are psychiatrists.

2. Maintaining outdated information. These directories often have inaccurate addresses and phone numbers, even including providers who are retired or deceased. For example, Maryland law requires plans to update their online provider directories every 15 days, but it is obvious that this does not happen, nor is it adequately policed. There is no incentive to weed out stale information if it keeps the size of the network large and there are no financial penalties to having wrong information. A few years ago, the Maryland Psychological Association called more than 900 providers from 7 online insurance directories to determine whether they could see a patient in the insurance plan. Forty-four percent of the listed providers were unreachable based on the contact information in the directories.

3. Including providers who have stopped taking new patients. When providers stop accepting new patients with XYZ Insurance, they should either not be listed in the online directory or it should indicate that they are not taking new patients, as this otherwise makes the network look more adequate than it really is. The language that establishes state health benefit exchanges in the Affordable Care Act specifically requires that provider directories indicate which providers are actually able to accept new patients. This will require health plans to have a mechanism for providers to indicate when they are full or have stopped accepting patients with that insurance.

4. Long waiting lists. It is common to hear from patients who are frustrated in finding a psychiatrist in their directory because the ones who they are able to contact and who are accepting new patients, are booked up and cannot see them for many weeks, sometimes two to three months. This is surely a sign of an inadequate network.

5. Including hospital-based inpatient providers who do not have an outpatient practice. I am a hospital-based psychiatrist and do not have an outpatient practice. I participate with most insurance plans for inpatient treatment, but my five similar colleagues and I remain in these directories despite my attempts to get either de-listed or indicated that I don’t accept outpatients. Including all these inpatient physicians make the network look more robust than it is.
The Maryland Psychiatric Society has a referral service that gets more than a hundred calls per month looking for a psychiatrist. The executive director, Kery Hummel, tells me that most of these callers have been through their provider directory and have been unable to find anyone to see them in a timely manner.

Some of them are literally in tears over this frustration. My hospital department secretary, Dee Flythe, handles 180 of these calls every month, trying to help them find providers.

Finally, there is inadequate policing of network adequacy by state regulators, so this remains largely a complaint-driven oversight. But, according to our Insurance Administration, few patients make it to the point of calling the regulators to complain about the directories being inaccurate and inadequate. Some simple changes could increase the accuracy and transparency of their true network, such as:

• secret shoppers
• provider updatable directories
• links in the online directories that make it easy for frustrated patients to send complaints to regulators about inaccurate and misleading directory information
• claims-driven directories that indicate who is accepting new outpatients

This last change, connecting the provider directories with the claims database, would provide the transparency needed to show who is taking new outpatients. The health plan could show right next to each provider’s name the number of initial outpatient visit codes submitted over the most recently available period, say, 12 months. Those providers who have not recently taken any new patients for this health plan would indicate zero claims, so a potential patient could quickly find those who are taking new patients. Such an innovative and transparent mechanism also would make it obvious to regulators and purchasers if the network appears to be inadequate.

The problem now is that the plans have no incentive to expose the inadequacy of their network directories, while the regulators lack the staff to police them sufficiently. This nonquantitative treatment limit, in violation of the Parity Act, will continue until we have final regulations that specifically address network adequacy and that include consequences that are more costly than the financial benefit to having inadequate networks.

What can you do? Report inaccurate and inadequate networks to your state insurance commissioner, and ask patients to do the same thing. Speak up about this problem with legislators, regulators, and reporters. Shining some light on this widespread problem might help to reduce this loophole and hold plans accountable for making care accessible.

The irony is that patients with chronic medical problems who have untreated mental health and substance abuse problems cost the plans more money in claims. You’d think they would be bending over backward to improve this problem.

—Steven Roy Daviss, M.D., DFAPA

DR. DAVISS is chair of the department of psychiatry at the University of Maryland’s Baltimore Washington Medical Center, chair of the APA Committee on Electronic Health Records, co-chair of the CCHIT Behavioral Health Work Group, and co-author of Shrink Rap: Three Psychiatrists Explain Their Work, published by Johns Hopkins University Press. In addition to @HITshrink on Twitter, he can be found at [email protected], and on the Shrink Rap blog.

I was invited to testify at a congressional forum last week by Congressman Chris Van Hollen about challenges in the implementation and enforcement of the Mental Health Parity and Addiction Equity Act (MHPAEA). Also present were Congressmen Jim Moran and Paul Tonko, and former Congressmen Patrick Kennedy and Jim Ramstad.  These dedicated representatives stayed past 9 p.m., reflecting their dedication and resolve to ensure that the Parity Act be fully implemented.

As most readers of Clinical Psychiatry News are aware, people with mental health and addiction problems have long been stigmatized and marginalized in the health care system, and this one action – passing the 2008 Parity Act – will prove to be a historic correction of this great wrong. Indeed, the first attempt to correct the discriminatory practices of the health insurance industry was passed in 1996, but the industry figured out how to get around the intent of that first Parity Act. The ongoing efforts to close these loopholes are currently stuck, with the lack of final regulations that would dictate to payers how MHPAEA will be implemented and enforced, despite the law being passed 4 years ago.

Even URAC, the standards-based accreditation organization that accredits health insurance plans, has beat the federal government by recently updating its standards to require health plans to clearly and effectively demonstrate compliance with the Parity Act. To my knowledge, this is the first organization to specifically build Parity Act compliance into its standards for accreditation.

There has been an interim final rule passed, but such temporary regulations lack the finality that makes health plans address the more challenging aspects of compliance, particularly the nonquantitative treatment limits, or NQTLs. One of the more pervasive, yet hidden, NQTLs is the inadequacy of behavioral health provider networks compared to that of primary care networks.

I believe that network adequacy is probably THE biggest barrier to accessing care for our patients. When I ask patients about any problems finding a primary care physician, they rarely have problems. But finding an in-network psychiatrist has become an overwhelming problem. The insurance plans do not maintain a large enough network of physicians who specialize in psychiatry, creating a bottleneck that makes it hard for patients to initiate treatment.

While there has been some reductions in the need to obtain prior authorizations for outpatient treatment, the loophole here is that if there are not enough psychiatrists in the network who can actually see the patients needing care, many patients go without. This effectively limits the number of claims a payer must pay out. This is a nonquantitative treatment limit that is more restrictive on the mental health and addictions side than on the physical health side.

You’d think that one could determine the adequacy of the network by the number of providers in it, but this number is not an accurate reflection of the true size of the network. Look more closely and you discover a number of tricks that inflate the apparent size of the network. Whether these “tricks” are intentional or not, they amount to – in my opinion – fraud. If you pay for a plan that has 40 doctors listed in its online provider directory, you expect that you can see most of these 40 doctors. If the truth was that there are only four who could actually see you, then this is false advertising. It is a form of treatment limitation that seems to be applied particularly to behavioral health much more than to primary care.

Here are five of the most common tricks used:

1. Mixing provider types in the directory, with no way to select out just one type. There may be 40 providers within 10 miles of your Zip code, but the psychologists, social workers, psychiatrists, psychiatric nurses, and counselors are all mixed in together, even though they each have different scopes of practice. This inflates the apparent size of the true network when only 6 of the 40 are psychiatrists.

2. Maintaining outdated information. These directories often have inaccurate addresses and phone numbers, even including providers who are retired or deceased. For example, Maryland law requires plans to update their online provider directories every 15 days, but it is obvious that this does not happen, nor is it adequately policed. There is no incentive to weed out stale information if it keeps the size of the network large and there are no financial penalties to having wrong information. A few years ago, the Maryland Psychological Association called more than 900 providers from 7 online insurance directories to determine whether they could see a patient in the insurance plan. Forty-four percent of the listed providers were unreachable based on the contact information in the directories.

3. Including providers who have stopped taking new patients. When providers stop accepting new patients with XYZ Insurance, they should either not be listed in the online directory or it should indicate that they are not taking new patients, as this otherwise makes the network look more adequate than it really is. The language that establishes state health benefit exchanges in the Affordable Care Act specifically requires that provider directories indicate which providers are actually able to accept new patients. This will require health plans to have a mechanism for providers to indicate when they are full or have stopped accepting patients with that insurance.

4. Long waiting lists. It is common to hear from patients who are frustrated in finding a psychiatrist in their directory because the ones who they are able to contact and who are accepting new patients, are booked up and cannot see them for many weeks, sometimes two to three months. This is surely a sign of an inadequate network.

5. Including hospital-based inpatient providers who do not have an outpatient practice. I am a hospital-based psychiatrist and do not have an outpatient practice. I participate with most insurance plans for inpatient treatment, but my five similar colleagues and I remain in these directories despite my attempts to get either de-listed or indicated that I don’t accept outpatients. Including all these inpatient physicians make the network look more robust than it is.
The Maryland Psychiatric Society has a referral service that gets more than a hundred calls per month looking for a psychiatrist. The executive director, Kery Hummel, tells me that most of these callers have been through their provider directory and have been unable to find anyone to see them in a timely manner.

Some of them are literally in tears over this frustration. My hospital department secretary, Dee Flythe, handles 180 of these calls every month, trying to help them find providers.

Finally, there is inadequate policing of network adequacy by state regulators, so this remains largely a complaint-driven oversight. But, according to our Insurance Administration, few patients make it to the point of calling the regulators to complain about the directories being inaccurate and inadequate. Some simple changes could increase the accuracy and transparency of their true network, such as:

• secret shoppers
• provider updatable directories
• links in the online directories that make it easy for frustrated patients to send complaints to regulators about inaccurate and misleading directory information
• claims-driven directories that indicate who is accepting new outpatients

This last change, connecting the provider directories with the claims database, would provide the transparency needed to show who is taking new outpatients. The health plan could show right next to each provider’s name the number of initial outpatient visit codes submitted over the most recently available period, say, 12 months. Those providers who have not recently taken any new patients for this health plan would indicate zero claims, so a potential patient could quickly find those who are taking new patients. Such an innovative and transparent mechanism also would make it obvious to regulators and purchasers if the network appears to be inadequate.

The problem now is that the plans have no incentive to expose the inadequacy of their network directories, while the regulators lack the staff to police them sufficiently. This nonquantitative treatment limit, in violation of the Parity Act, will continue until we have final regulations that specifically address network adequacy and that include consequences that are more costly than the financial benefit to having inadequate networks.

What can you do? Report inaccurate and inadequate networks to your state insurance commissioner, and ask patients to do the same thing. Speak up about this problem with legislators, regulators, and reporters. Shining some light on this widespread problem might help to reduce this loophole and hold plans accountable for making care accessible.

The irony is that patients with chronic medical problems who have untreated mental health and substance abuse problems cost the plans more money in claims. You’d think they would be bending over backward to improve this problem.

—Steven Roy Daviss, M.D., DFAPA

DR. DAVISS is chair of the department of psychiatry at the University of Maryland’s Baltimore Washington Medical Center, chair of the APA Committee on Electronic Health Records, co-chair of the CCHIT Behavioral Health Work Group, and co-author of Shrink Rap: Three Psychiatrists Explain Their Work, published by Johns Hopkins University Press. In addition to @HITshrink on Twitter, he can be found at [email protected], and on the Shrink Rap blog.

I was invited to testify at a congressional forum last week by Congressman Chris Van Hollen about challenges in the implementation and enforcement of the Mental Health Parity and Addiction Equity Act (MHPAEA). Also present were Congressmen Jim Moran and Paul Tonko, and former Congressmen Patrick Kennedy and Jim Ramstad.  These dedicated representatives stayed past 9 p.m., reflecting their dedication and resolve to ensure that the Parity Act be fully implemented.

As most readers of Clinical Psychiatry News are aware, people with mental health and addiction problems have long been stigmatized and marginalized in the health care system, and this one action – passing the 2008 Parity Act – will prove to be a historic correction of this great wrong. Indeed, the first attempt to correct the discriminatory practices of the health insurance industry was passed in 1996, but the industry figured out how to get around the intent of that first Parity Act. The ongoing efforts to close these loopholes are currently stuck, with the lack of final regulations that would dictate to payers how MHPAEA will be implemented and enforced, despite the law being passed 4 years ago.

Even URAC, the standards-based accreditation organization that accredits health insurance plans, has beat the federal government by recently updating its standards to require health plans to clearly and effectively demonstrate compliance with the Parity Act. To my knowledge, this is the first organization to specifically build Parity Act compliance into its standards for accreditation.

There has been an interim final rule passed, but such temporary regulations lack the finality that makes health plans address the more challenging aspects of compliance, particularly the nonquantitative treatment limits, or NQTLs. One of the more pervasive, yet hidden, NQTLs is the inadequacy of behavioral health provider networks compared to that of primary care networks.

I believe that network adequacy is probably THE biggest barrier to accessing care for our patients. When I ask patients about any problems finding a primary care physician, they rarely have problems. But finding an in-network psychiatrist has become an overwhelming problem. The insurance plans do not maintain a large enough network of physicians who specialize in psychiatry, creating a bottleneck that makes it hard for patients to initiate treatment.

While there has been some reductions in the need to obtain prior authorizations for outpatient treatment, the loophole here is that if there are not enough psychiatrists in the network who can actually see the patients needing care, many patients go without. This effectively limits the number of claims a payer must pay out. This is a nonquantitative treatment limit that is more restrictive on the mental health and addictions side than on the physical health side.

You’d think that one could determine the adequacy of the network by the number of providers in it, but this number is not an accurate reflection of the true size of the network. Look more closely and you discover a number of tricks that inflate the apparent size of the network. Whether these “tricks” are intentional or not, they amount to – in my opinion – fraud. If you pay for a plan that has 40 doctors listed in its online provider directory, you expect that you can see most of these 40 doctors. If the truth was that there are only four who could actually see you, then this is false advertising. It is a form of treatment limitation that seems to be applied particularly to behavioral health much more than to primary care.

Here are five of the most common tricks used:

1. Mixing provider types in the directory, with no way to select out just one type. There may be 40 providers within 10 miles of your Zip code, but the psychologists, social workers, psychiatrists, psychiatric nurses, and counselors are all mixed in together, even though they each have different scopes of practice. This inflates the apparent size of the true network when only 6 of the 40 are psychiatrists.

2. Maintaining outdated information. These directories often have inaccurate addresses and phone numbers, even including providers who are retired or deceased. For example, Maryland law requires plans to update their online provider directories every 15 days, but it is obvious that this does not happen, nor is it adequately policed. There is no incentive to weed out stale information if it keeps the size of the network large and there are no financial penalties to having wrong information. A few years ago, the Maryland Psychological Association called more than 900 providers from 7 online insurance directories to determine whether they could see a patient in the insurance plan. Forty-four percent of the listed providers were unreachable based on the contact information in the directories.

3. Including providers who have stopped taking new patients. When providers stop accepting new patients with XYZ Insurance, they should either not be listed in the online directory or it should indicate that they are not taking new patients, as this otherwise makes the network look more adequate than it really is. The language that establishes state health benefit exchanges in the Affordable Care Act specifically requires that provider directories indicate which providers are actually able to accept new patients. This will require health plans to have a mechanism for providers to indicate when they are full or have stopped accepting patients with that insurance.

4. Long waiting lists. It is common to hear from patients who are frustrated in finding a psychiatrist in their directory because the ones who they are able to contact and who are accepting new patients, are booked up and cannot see them for many weeks, sometimes two to three months. This is surely a sign of an inadequate network.

5. Including hospital-based inpatient providers who do not have an outpatient practice. I am a hospital-based psychiatrist and do not have an outpatient practice. I participate with most insurance plans for inpatient treatment, but my five similar colleagues and I remain in these directories despite my attempts to get either de-listed or indicated that I don’t accept outpatients. Including all these inpatient physicians make the network look more robust than it is.
The Maryland Psychiatric Society has a referral service that gets more than a hundred calls per month looking for a psychiatrist. The executive director, Kery Hummel, tells me that most of these callers have been through their provider directory and have been unable to find anyone to see them in a timely manner.

Some of them are literally in tears over this frustration. My hospital department secretary, Dee Flythe, handles 180 of these calls every month, trying to help them find providers.

Finally, there is inadequate policing of network adequacy by state regulators, so this remains largely a complaint-driven oversight. But, according to our Insurance Administration, few patients make it to the point of calling the regulators to complain about the directories being inaccurate and inadequate. Some simple changes could increase the accuracy and transparency of their true network, such as:

• secret shoppers
• provider updatable directories
• links in the online directories that make it easy for frustrated patients to send complaints to regulators about inaccurate and misleading directory information
• claims-driven directories that indicate who is accepting new outpatients

This last change, connecting the provider directories with the claims database, would provide the transparency needed to show who is taking new outpatients. The health plan could show right next to each provider’s name the number of initial outpatient visit codes submitted over the most recently available period, say, 12 months. Those providers who have not recently taken any new patients for this health plan would indicate zero claims, so a potential patient could quickly find those who are taking new patients. Such an innovative and transparent mechanism also would make it obvious to regulators and purchasers if the network appears to be inadequate.

The problem now is that the plans have no incentive to expose the inadequacy of their network directories, while the regulators lack the staff to police them sufficiently. This nonquantitative treatment limit, in violation of the Parity Act, will continue until we have final regulations that specifically address network adequacy and that include consequences that are more costly than the financial benefit to having inadequate networks.

What can you do? Report inaccurate and inadequate networks to your state insurance commissioner, and ask patients to do the same thing. Speak up about this problem with legislators, regulators, and reporters. Shining some light on this widespread problem might help to reduce this loophole and hold plans accountable for making care accessible.

The irony is that patients with chronic medical problems who have untreated mental health and substance abuse problems cost the plans more money in claims. You’d think they would be bending over backward to improve this problem.

—Steven Roy Daviss, M.D., DFAPA

DR. DAVISS is chair of the department of psychiatry at the University of Maryland’s Baltimore Washington Medical Center, chair of the APA Committee on Electronic Health Records, co-chair of the CCHIT Behavioral Health Work Group, and co-author of Shrink Rap: Three Psychiatrists Explain Their Work, published by Johns Hopkins University Press. In addition to @HITshrink on Twitter, he can be found at [email protected], and on the Shrink Rap blog.

As the U.S. Supreme Court announced its decision regarding the Affordable Care Act, another landmark health care case was filed in federal district court. Baycote v. Federal Bureau of Prisons is a class action suit by inmates of the federal control unit (or “SuperMax”) facility in Florence, Colo. It was filed by attorneys from the Washington Lawyers’ Committee for Civil Rights and Urban Affairs with pro bono assistance from a private law firm. The federal prison, also known as ADX, provides the highest level of security in the federal prison system and is renown for the notoriety of its inmates such as Unabomber Ted Kaczynski and the late Oklahoma City bomber Timothy McVeigh.

The suit alleges multiple egregious violations of the Eighth Amendment prohibition against cruel and unusual punishment. Plaintiffs claim that correctional officers routinely were physically and emotionally abusive and that the facility failed to provide necessary mental health screening and treatment. The full suit covers more than a hundred pages and can be reviewed online. A recent three-part series of articles discussing the suit by Andrew Cohen was published simultaneously this week in the Atlantic.

The allegations in the suit are extremely serious. Inmates point to incidents in which they were shackled in four point restraints to a cement wall and denied food or bathroom privileges. They allege emotionally abusive tactics such as threats, humiliation, and mocking of mentally ill prisoners. When the plaintiffs filed administrative complaints, they allege that these internal complaints were “lost” or otherwise destroyed, and that the facility or system retaliated against them.

The Code of Federal Regulations prohibits the housing of mentally ill inmates in ADX. The regulations also require a mental health evaluation within 30 days of arrival, and every month after that, with provision of therapy or medication as needed. The Baycote suit alleges that the facility inappropriately housed ill inmates at Florence and that mental health services were inadequate for their care. It alleges perfunctory intake screening, non-confidential therapy sessions, failure to make a diagnosis or to consider diagnoses made at other facilities, and inappropriate discontinuation of medication. The suit also alleges that mental health staff improperly participated in law enforcement activities such as manning a gun tower, participating in cell extractions, and escorting prisoners while wearing a weapon.

The plaintiffs in this case are hardly model citizens. The lead plaintiff murdered a fellow inmate, another stabbed a witness in a courtroom, another attacked a prison chaplain, and one held a staff member hostage at knifepoint in another facility. The lawsuit implies that these actions were the result of untreated mental illness. Andrew Cohen, in the Atlantic series, casually dismisses their level of dangerousness as being “hardly noble.”

What the Atlantic articles and the Baycote complaint do not mention is the dilemma faced by the prison and prison clinicians when treating inmates like this. Inmates with severe antisocial personality disorder press the limits of our diagnostic criteria. People with severe personality disorders often have histories of trauma, cognitive deficits, co-existing mood disorders as well as learned maladaptive behaviors. Treatment options are limited, unproven, and likely to have a poor prognosis with each additional layer of pathology. At least one of these plaintiffs had been treated with a series of medications prior to transfer, which to me indicates heroic efforts to manage violence pharmacologically. The decision to stop medication at ADX could certainly be seen as a final recognition that medication was simply not the answer.

Reasonable clinicians at different facilities can legitimately disagree about treatment, and these disagreements should not be taken as evidence of neglect, abuse or abandonment. Security is also a necessary component of treatment for severe personality disorders, and a control unit environment can provide that security.

Similarly, a regulation that forbids housing of the mentally ill leaves the facility in a conundrum, a logical paradox in which the clinician has to negotiate a bizarre line of circular reasoning. If an inmate is eligible for ADX because of violence, and violence is indicative of severe mental illness which requires treatment, then by definition they cannot be housed in a control unit environment. This type of regulation is what drives correctional psychiatrists screaming into the night.

I agree that no inmate should be subject to abuse or neglect. My concern is that legitimate grievances and problems will be papered over with inflammatory prose. When attorneys and journalists refer to “unspeakable cruelty and wickedness” in connection with a facility or its clinicians, or fling about adjectives like “callous, inhumane, deplorable, barbaric, and torture,” we get caught up in controversy rather than focusing our efforts to improve services.

Cohen refers to “…an eternal truth of civilized life on this planet; prisons are always worse than the officials who run them say they are.”

Another eternal truth is that jails and prisons often are never as bad as the media portrays them.

—Annette Hanson

Dr. Hanson is a forensic psychiatrist and co-author of Shrink Rap: Three Psychiatrists Explain Their Work. The opinions expressed are those of the author only, and do not represent those of any of Dr. Hanson’s employers or consultees, including the Maryland Department of Health and Mental Hygiene or the Maryland Division of Correction.

As the U.S. Supreme Court announced its decision regarding the Affordable Care Act, another landmark health care case was filed in federal district court. Baycote v. Federal Bureau of Prisons is a class action suit by inmates of the federal control unit (or “SuperMax”) facility in Florence, Colo. It was filed by attorneys from the Washington Lawyers’ Committee for Civil Rights and Urban Affairs with pro bono assistance from a private law firm. The federal prison, also known as ADX, provides the highest level of security in the federal prison system and is renown for the notoriety of its inmates such as Unabomber Ted Kaczynski and the late Oklahoma City bomber Timothy McVeigh.

The suit alleges multiple egregious violations of the Eighth Amendment prohibition against cruel and unusual punishment. Plaintiffs claim that correctional officers routinely were physically and emotionally abusive and that the facility failed to provide necessary mental health screening and treatment. The full suit covers more than a hundred pages and can be reviewed online. A recent three-part series of articles discussing the suit by Andrew Cohen was published simultaneously this week in the Atlantic.

The allegations in the suit are extremely serious. Inmates point to incidents in which they were shackled in four point restraints to a cement wall and denied food or bathroom privileges. They allege emotionally abusive tactics such as threats, humiliation, and mocking of mentally ill prisoners. When the plaintiffs filed administrative complaints, they allege that these internal complaints were “lost” or otherwise destroyed, and that the facility or system retaliated against them.

The Code of Federal Regulations prohibits the housing of mentally ill inmates in ADX. The regulations also require a mental health evaluation within 30 days of arrival, and every month after that, with provision of therapy or medication as needed. The Baycote suit alleges that the facility inappropriately housed ill inmates at Florence and that mental health services were inadequate for their care. It alleges perfunctory intake screening, non-confidential therapy sessions, failure to make a diagnosis or to consider diagnoses made at other facilities, and inappropriate discontinuation of medication. The suit also alleges that mental health staff improperly participated in law enforcement activities such as manning a gun tower, participating in cell extractions, and escorting prisoners while wearing a weapon.

The plaintiffs in this case are hardly model citizens. The lead plaintiff murdered a fellow inmate, another stabbed a witness in a courtroom, another attacked a prison chaplain, and one held a staff member hostage at knifepoint in another facility. The lawsuit implies that these actions were the result of untreated mental illness. Andrew Cohen, in the Atlantic series, casually dismisses their level of dangerousness as being “hardly noble.”

What the Atlantic articles and the Baycote complaint do not mention is the dilemma faced by the prison and prison clinicians when treating inmates like this. Inmates with severe antisocial personality disorder press the limits of our diagnostic criteria. People with severe personality disorders often have histories of trauma, cognitive deficits, co-existing mood disorders as well as learned maladaptive behaviors. Treatment options are limited, unproven, and likely to have a poor prognosis with each additional layer of pathology. At least one of these plaintiffs had been treated with a series of medications prior to transfer, which to me indicates heroic efforts to manage violence pharmacologically. The decision to stop medication at ADX could certainly be seen as a final recognition that medication was simply not the answer.

Reasonable clinicians at different facilities can legitimately disagree about treatment, and these disagreements should not be taken as evidence of neglect, abuse or abandonment. Security is also a necessary component of treatment for severe personality disorders, and a control unit environment can provide that security.

Similarly, a regulation that forbids housing of the mentally ill leaves the facility in a conundrum, a logical paradox in which the clinician has to negotiate a bizarre line of circular reasoning. If an inmate is eligible for ADX because of violence, and violence is indicative of severe mental illness which requires treatment, then by definition they cannot be housed in a control unit environment. This type of regulation is what drives correctional psychiatrists screaming into the night.

I agree that no inmate should be subject to abuse or neglect. My concern is that legitimate grievances and problems will be papered over with inflammatory prose. When attorneys and journalists refer to “unspeakable cruelty and wickedness” in connection with a facility or its clinicians, or fling about adjectives like “callous, inhumane, deplorable, barbaric, and torture,” we get caught up in controversy rather than focusing our efforts to improve services.

Cohen refers to “…an eternal truth of civilized life on this planet; prisons are always worse than the officials who run them say they are.”

Another eternal truth is that jails and prisons often are never as bad as the media portrays them.

—Annette Hanson

Dr. Hanson is a forensic psychiatrist and co-author of Shrink Rap: Three Psychiatrists Explain Their Work. The opinions expressed are those of the author only, and do not represent those of any of Dr. Hanson’s employers or consultees, including the Maryland Department of Health and Mental Hygiene or the Maryland Division of Correction.

As the U.S. Supreme Court announced its decision regarding the Affordable Care Act, another landmark health care case was filed in federal district court. Baycote v. Federal Bureau of Prisons is a class action suit by inmates of the federal control unit (or “SuperMax”) facility in Florence, Colo. It was filed by attorneys from the Washington Lawyers’ Committee for Civil Rights and Urban Affairs with pro bono assistance from a private law firm. The federal prison, also known as ADX, provides the highest level of security in the federal prison system and is renown for the notoriety of its inmates such as Unabomber Ted Kaczynski and the late Oklahoma City bomber Timothy McVeigh.

The suit alleges multiple egregious violations of the Eighth Amendment prohibition against cruel and unusual punishment. Plaintiffs claim that correctional officers routinely were physically and emotionally abusive and that the facility failed to provide necessary mental health screening and treatment. The full suit covers more than a hundred pages and can be reviewed online. A recent three-part series of articles discussing the suit by Andrew Cohen was published simultaneously this week in the Atlantic.

The allegations in the suit are extremely serious. Inmates point to incidents in which they were shackled in four point restraints to a cement wall and denied food or bathroom privileges. They allege emotionally abusive tactics such as threats, humiliation, and mocking of mentally ill prisoners. When the plaintiffs filed administrative complaints, they allege that these internal complaints were “lost” or otherwise destroyed, and that the facility or system retaliated against them.

The Code of Federal Regulations prohibits the housing of mentally ill inmates in ADX. The regulations also require a mental health evaluation within 30 days of arrival, and every month after that, with provision of therapy or medication as needed. The Baycote suit alleges that the facility inappropriately housed ill inmates at Florence and that mental health services were inadequate for their care. It alleges perfunctory intake screening, non-confidential therapy sessions, failure to make a diagnosis or to consider diagnoses made at other facilities, and inappropriate discontinuation of medication. The suit also alleges that mental health staff improperly participated in law enforcement activities such as manning a gun tower, participating in cell extractions, and escorting prisoners while wearing a weapon.

The plaintiffs in this case are hardly model citizens. The lead plaintiff murdered a fellow inmate, another stabbed a witness in a courtroom, another attacked a prison chaplain, and one held a staff member hostage at knifepoint in another facility. The lawsuit implies that these actions were the result of untreated mental illness. Andrew Cohen, in the Atlantic series, casually dismisses their level of dangerousness as being “hardly noble.”

What the Atlantic articles and the Baycote complaint do not mention is the dilemma faced by the prison and prison clinicians when treating inmates like this. Inmates with severe antisocial personality disorder press the limits of our diagnostic criteria. People with severe personality disorders often have histories of trauma, cognitive deficits, co-existing mood disorders as well as learned maladaptive behaviors. Treatment options are limited, unproven, and likely to have a poor prognosis with each additional layer of pathology. At least one of these plaintiffs had been treated with a series of medications prior to transfer, which to me indicates heroic efforts to manage violence pharmacologically. The decision to stop medication at ADX could certainly be seen as a final recognition that medication was simply not the answer.

Reasonable clinicians at different facilities can legitimately disagree about treatment, and these disagreements should not be taken as evidence of neglect, abuse or abandonment. Security is also a necessary component of treatment for severe personality disorders, and a control unit environment can provide that security.

Similarly, a regulation that forbids housing of the mentally ill leaves the facility in a conundrum, a logical paradox in which the clinician has to negotiate a bizarre line of circular reasoning. If an inmate is eligible for ADX because of violence, and violence is indicative of severe mental illness which requires treatment, then by definition they cannot be housed in a control unit environment. This type of regulation is what drives correctional psychiatrists screaming into the night.

I agree that no inmate should be subject to abuse or neglect. My concern is that legitimate grievances and problems will be papered over with inflammatory prose. When attorneys and journalists refer to “unspeakable cruelty and wickedness” in connection with a facility or its clinicians, or fling about adjectives like “callous, inhumane, deplorable, barbaric, and torture,” we get caught up in controversy rather than focusing our efforts to improve services.

Cohen refers to “…an eternal truth of civilized life on this planet; prisons are always worse than the officials who run them say they are.”

Another eternal truth is that jails and prisons often are never as bad as the media portrays them.

—Annette Hanson

Dr. Hanson is a forensic psychiatrist and co-author of Shrink Rap: Three Psychiatrists Explain Their Work. The opinions expressed are those of the author only, and do not represent those of any of Dr. Hanson’s employers or consultees, including the Maryland Department of Health and Mental Hygiene or the Maryland Division of Correction.

If you went to APA this year, or any year, you know there are people who don’t like psychiatrists. Traditionally, we’ve referred to them as being part of the “Anti-Psychiatry” movement, but I’ve come to realize, through years of writing a psychiatry blog, that there are shades of grey here (though not necessarily 50). I’ve stopped lumping everyone who is critical of our work together in one category as “anti-psychiatry” because our critics differ as to just how "anti" they are. Instead, I’ve come to loosely refer to them as “The Haters.” It’s probably an awful term because adults cringe at the word “hate,” but I borrowed it from my teenage children who seem to use it freely, and if you look in UrbanDictionary.com, you’ll find that there are seven definitions for the term “hater.” For my purposes, I like #6 the best:

A label applied to people who are more negative than positive when discussing another person. It most commonly refers to individuals whose negativity is so extreme that it is all-consuming. However, there are various levels and forms of being a hater, ranging from completely dismissing any positive traits or actions, to merely painting a less than flattering picture by using words with negative connotations. Hating is often attributed to jealousy, but just as often, it seems to stem from some other source.

For my own personal use, psychiatry “haters,” used facetiously, include all of those people who are outspoken against our work. It seems too easy to lump our critics together in a single category of radical anti-psychiatry proponents: those who march with signs saying “Psychiatry Kills,” or who show up at APA with jumbotrons or who chant in unison, “Stop drugging and shocking our children!” It’s easy to dismiss the concerns of those who belong to the anti-psychiatry movement; they don’t understand what we do, they are over-the-top; and they aren’t interested in a having a discussion with us. But they do have power and they do influence how others (including legislators), see our field.

While many haters are angry, many have valid messages--ones we should consider, engage with them about, and use to look more closely at our field. I’ve broken the haters down into a few categories. Please note, these are my own observations. These are not validated classifications and the is no peer-reviewed research available on psychiatry haters. Perhaps there should be.

So “haters” exist along a spectrum:

• There are those that believe that psychiatry as a field should be abolished. Psychiatry inflicts harm, and if you feel it’s been helpful to you, you’re wrong. Those aren’t symptoms you’re having: your problems are the result of the medications, which cause perfectly normal people to become crazy. Mental illness isn’t real, it was created to benefit psychiatrists. Psychotropic medications should be illegal, and no one should be prescribed them. These haters are the traditional anti-psychiatry movement members.

• There are haters who are angry for individual reasons. Perhaps they had a bad reaction to medication, or are angry about events pertaining to hospitalization. They may openly discuss their distress in books, on blogs, or on listservs, but they don’t believe that psychiatry should be abolished or that no one else should be permitted to take medications. It is important to listen to these stories, to validate distressing experience, and to ask if there are different ways of approaching problems— certainly for the individual in question, and perhaps as such issues pertain to other patients as well.

• There are haters who specifically feel that the pharmaceutical companies have deceived the public and medical professionals, and have tainted psychiatric care toward a bias of overusing, or inappropriately using, medications. They may be right (or am I a hater?).

• There are haters who focus on psychiatry as an instrument of control, and they talk about authority imbalances, the wrongness of forced care for those who are dangerous, and philosophical issues of power. Sometimes, it is difficult to navigate these discussions.

• There are haters who have had bad experiences with a single doctor and who generalize this to all of psychiatry. Perhaps their bad experiences were the result of poor interpersonal chemistry, an elevated degree of sensitivity to human interactions, overly high expectations, or perhaps they simply had a bad experience with a bad psychiatrist. Sometimes a subsequent, more positive, experience helps the individual become less of a hater.

• There are haters who are angry because they lack insight into their illness and view their behavior or emotions as being normal when others do not. They may feel they were forced, or unduly cajoled, into getting psychiatric care, and if they played a role in creating a difficult situation, they may not see it. These are really difficult situations for everyone involved.

I’ve probably missed a few “hater” subsets. As a field, I believe we’ve gotten better about considering the concerns of those who criticize us. As we work to find better treatments for our patients, we need to remain open to hearing out those who feel they have been wronged by psychiatrists and psychiatric treatments. There are certainly moments when we can learn from the haters and when they can learn from us. Education and open communication go a long way toward letting those who need help actually get it in a way that comforts, rather than antagonizes, the patient.

Other articles:

From Shrink Rap: Top Ten Things That Annoy Me About Psychiatry Haters from Psychiatric Times, May 24, 2012, “Moving Beyond Hatred of Psychiatry: A Brave Voice Speaks Out,” by Ronald Pies, M.D. (May require subscription to Psychiatric Times)

--- by Dinah Miller, M.D. 

DR. MILLER is the co-author of Shrink Rap: Three Psychiatrists Explain Their Work, published by Johns Hopkins University Press.

If you went to APA this year, or any year, you know there are people who don’t like psychiatrists. Traditionally, we’ve referred to them as being part of the “Anti-Psychiatry” movement, but I’ve come to realize, through years of writing a psychiatry blog, that there are shades of grey here (though not necessarily 50). I’ve stopped lumping everyone who is critical of our work together in one category as “anti-psychiatry” because our critics differ as to just how "anti" they are. Instead, I’ve come to loosely refer to them as “The Haters.” It’s probably an awful term because adults cringe at the word “hate,” but I borrowed it from my teenage children who seem to use it freely, and if you look in UrbanDictionary.com, you’ll find that there are seven definitions for the term “hater.” For my purposes, I like #6 the best:

A label applied to people who are more negative than positive when discussing another person. It most commonly refers to individuals whose negativity is so extreme that it is all-consuming. However, there are various levels and forms of being a hater, ranging from completely dismissing any positive traits or actions, to merely painting a less than flattering picture by using words with negative connotations. Hating is often attributed to jealousy, but just as often, it seems to stem from some other source.

For my own personal use, psychiatry “haters,” used facetiously, include all of those people who are outspoken against our work. It seems too easy to lump our critics together in a single category of radical anti-psychiatry proponents: those who march with signs saying “Psychiatry Kills,” or who show up at APA with jumbotrons or who chant in unison, “Stop drugging and shocking our children!” It’s easy to dismiss the concerns of those who belong to the anti-psychiatry movement; they don’t understand what we do, they are over-the-top; and they aren’t interested in a having a discussion with us. But they do have power and they do influence how others (including legislators), see our field.

While many haters are angry, many have valid messages--ones we should consider, engage with them about, and use to look more closely at our field. I’ve broken the haters down into a few categories. Please note, these are my own observations. These are not validated classifications and the is no peer-reviewed research available on psychiatry haters. Perhaps there should be.

So “haters” exist along a spectrum:

• There are those that believe that psychiatry as a field should be abolished. Psychiatry inflicts harm, and if you feel it’s been helpful to you, you’re wrong. Those aren’t symptoms you’re having: your problems are the result of the medications, which cause perfectly normal people to become crazy. Mental illness isn’t real, it was created to benefit psychiatrists. Psychotropic medications should be illegal, and no one should be prescribed them. These haters are the traditional anti-psychiatry movement members.

• There are haters who are angry for individual reasons. Perhaps they had a bad reaction to medication, or are angry about events pertaining to hospitalization. They may openly discuss their distress in books, on blogs, or on listservs, but they don’t believe that psychiatry should be abolished or that no one else should be permitted to take medications. It is important to listen to these stories, to validate distressing experience, and to ask if there are different ways of approaching problems— certainly for the individual in question, and perhaps as such issues pertain to other patients as well.

• There are haters who specifically feel that the pharmaceutical companies have deceived the public and medical professionals, and have tainted psychiatric care toward a bias of overusing, or inappropriately using, medications. They may be right (or am I a hater?).

• There are haters who focus on psychiatry as an instrument of control, and they talk about authority imbalances, the wrongness of forced care for those who are dangerous, and philosophical issues of power. Sometimes, it is difficult to navigate these discussions.

• There are haters who have had bad experiences with a single doctor and who generalize this to all of psychiatry. Perhaps their bad experiences were the result of poor interpersonal chemistry, an elevated degree of sensitivity to human interactions, overly high expectations, or perhaps they simply had a bad experience with a bad psychiatrist. Sometimes a subsequent, more positive, experience helps the individual become less of a hater.

• There are haters who are angry because they lack insight into their illness and view their behavior or emotions as being normal when others do not. They may feel they were forced, or unduly cajoled, into getting psychiatric care, and if they played a role in creating a difficult situation, they may not see it. These are really difficult situations for everyone involved.

I’ve probably missed a few “hater” subsets. As a field, I believe we’ve gotten better about considering the concerns of those who criticize us. As we work to find better treatments for our patients, we need to remain open to hearing out those who feel they have been wronged by psychiatrists and psychiatric treatments. There are certainly moments when we can learn from the haters and when they can learn from us. Education and open communication go a long way toward letting those who need help actually get it in a way that comforts, rather than antagonizes, the patient.

Other articles:

From Shrink Rap: Top Ten Things That Annoy Me About Psychiatry Haters from Psychiatric Times, May 24, 2012, “Moving Beyond Hatred of Psychiatry: A Brave Voice Speaks Out,” by Ronald Pies, M.D. (May require subscription to Psychiatric Times)

--- by Dinah Miller, M.D. 

DR. MILLER is the co-author of Shrink Rap: Three Psychiatrists Explain Their Work, published by Johns Hopkins University Press.

If you went to APA this year, or any year, you know there are people who don’t like psychiatrists. Traditionally, we’ve referred to them as being part of the “Anti-Psychiatry” movement, but I’ve come to realize, through years of writing a psychiatry blog, that there are shades of grey here (though not necessarily 50). I’ve stopped lumping everyone who is critical of our work together in one category as “anti-psychiatry” because our critics differ as to just how "anti" they are. Instead, I’ve come to loosely refer to them as “The Haters.” It’s probably an awful term because adults cringe at the word “hate,” but I borrowed it from my teenage children who seem to use it freely, and if you look in UrbanDictionary.com, you’ll find that there are seven definitions for the term “hater.” For my purposes, I like #6 the best:

A label applied to people who are more negative than positive when discussing another person. It most commonly refers to individuals whose negativity is so extreme that it is all-consuming. However, there are various levels and forms of being a hater, ranging from completely dismissing any positive traits or actions, to merely painting a less than flattering picture by using words with negative connotations. Hating is often attributed to jealousy, but just as often, it seems to stem from some other source.

For my own personal use, psychiatry “haters,” used facetiously, include all of those people who are outspoken against our work. It seems too easy to lump our critics together in a single category of radical anti-psychiatry proponents: those who march with signs saying “Psychiatry Kills,” or who show up at APA with jumbotrons or who chant in unison, “Stop drugging and shocking our children!” It’s easy to dismiss the concerns of those who belong to the anti-psychiatry movement; they don’t understand what we do, they are over-the-top; and they aren’t interested in a having a discussion with us. But they do have power and they do influence how others (including legislators), see our field.

While many haters are angry, many have valid messages--ones we should consider, engage with them about, and use to look more closely at our field. I’ve broken the haters down into a few categories. Please note, these are my own observations. These are not validated classifications and the is no peer-reviewed research available on psychiatry haters. Perhaps there should be.

So “haters” exist along a spectrum:

• There are those that believe that psychiatry as a field should be abolished. Psychiatry inflicts harm, and if you feel it’s been helpful to you, you’re wrong. Those aren’t symptoms you’re having: your problems are the result of the medications, which cause perfectly normal people to become crazy. Mental illness isn’t real, it was created to benefit psychiatrists. Psychotropic medications should be illegal, and no one should be prescribed them. These haters are the traditional anti-psychiatry movement members.

• There are haters who are angry for individual reasons. Perhaps they had a bad reaction to medication, or are angry about events pertaining to hospitalization. They may openly discuss their distress in books, on blogs, or on listservs, but they don’t believe that psychiatry should be abolished or that no one else should be permitted to take medications. It is important to listen to these stories, to validate distressing experience, and to ask if there are different ways of approaching problems— certainly for the individual in question, and perhaps as such issues pertain to other patients as well.

• There are haters who specifically feel that the pharmaceutical companies have deceived the public and medical professionals, and have tainted psychiatric care toward a bias of overusing, or inappropriately using, medications. They may be right (or am I a hater?).

• There are haters who focus on psychiatry as an instrument of control, and they talk about authority imbalances, the wrongness of forced care for those who are dangerous, and philosophical issues of power. Sometimes, it is difficult to navigate these discussions.

• There are haters who have had bad experiences with a single doctor and who generalize this to all of psychiatry. Perhaps their bad experiences were the result of poor interpersonal chemistry, an elevated degree of sensitivity to human interactions, overly high expectations, or perhaps they simply had a bad experience with a bad psychiatrist. Sometimes a subsequent, more positive, experience helps the individual become less of a hater.

• There are haters who are angry because they lack insight into their illness and view their behavior or emotions as being normal when others do not. They may feel they were forced, or unduly cajoled, into getting psychiatric care, and if they played a role in creating a difficult situation, they may not see it. These are really difficult situations for everyone involved.

I’ve probably missed a few “hater” subsets. As a field, I believe we’ve gotten better about considering the concerns of those who criticize us. As we work to find better treatments for our patients, we need to remain open to hearing out those who feel they have been wronged by psychiatrists and psychiatric treatments. There are certainly moments when we can learn from the haters and when they can learn from us. Education and open communication go a long way toward letting those who need help actually get it in a way that comforts, rather than antagonizes, the patient.

Other articles:

From Shrink Rap: Top Ten Things That Annoy Me About Psychiatry Haters from Psychiatric Times, May 24, 2012, “Moving Beyond Hatred of Psychiatry: A Brave Voice Speaks Out,” by Ronald Pies, M.D. (May require subscription to Psychiatric Times)

--- by Dinah Miller, M.D. 

DR. MILLER is the co-author of Shrink Rap: Three Psychiatrists Explain Their Work, published by Johns Hopkins University Press.

You’ve probably read something about the Health Benefit Exchange (HBE) system that comes out of the Accountable Care Act (ACA). At the time I’m writing this, the Supreme Court has yet to render its opinion about the ACA’s constitutionality. But the Health Benefit Exchange is intended to be a marketplace for insurance plans that meet certain rules and have certain minimal essential health benefits, referred to as Qualified Health Plans or QHPs.

Every state is deciding whether or not to implement an HBE; most of them are, especially given the fact that the federal government will fund 90% of the cost for the first 2 years – seed money, if you will, for the states to get this up and running. Afterward, the cost-sharing reverts back to what it is for all Medicaid recipients, with the feds paying around 40-50% of the Medicaid costs.

I am on one of the advisory committees for Maryland’s HBE, and we just had our first meeting. This is the Plan Management Committee, whose purpose is to collect state-specific perspectives from key stakeholders to inform policy decisions to ensure that the Exchange meets the needs of Maryland residents.

Specifically, we are being asked to be sure that we have sufficient rules in place to ensure that the plans meet federal and state requirements for “qualified plans.” We are also being asked to comment on the following areas and questions:

• Plan Certification, Recertification & Decertification Standards                          What certification, recertification and decertification rules should be adopted?                                                                                                         Should the Exchange require a standardized plan to be offered at each metal level? 

• Health Disparity Reduction                                                                              How can certification standards be used to reduce disparities?

• Pricing of Dental & Vision Plans                                                                     How should dental and vision plan pricing be presented to consumers     to balance accessibility and affordability?

• Plan Choice Architecture                                                                                   How can plan information be presented to best assist consumers to          choose a plan on criteria other than price?

              Should Maryland limit the number of qualified plans issuers can submit               to the Exchange?

If you have not stopped reading this column yet, you are probably asking what any of this has to do with psychiatry. Everything.

These plans need to be in place by 2014, but the rules about what they need to look like and what services they offer need to be developed now. Qualified plans will need to satisfy the Mental Health Parity and Addiction Equity Act, but there is still a lot of confusion about what that means.

Despite this Act becoming law in 2008, there are still no final regulations about how plans can ensure compliance. And, it is starting to look like we won’t see final regulations until after 2014. So, it is important to have stakeholders at these meetings to ensure that they get it right. I attend the meetings, holding my mental health stake, hoping that I can get it right.

That first bullet, about Certification, means the group of 20 or so stakeholders at this meeting must learn about the federal and state law about what the certification standards are, and be sure that we make recommendations to ensure that HBE plans are compliant. I know this includes compliance with the parity law and will come prepared to explain that when the time comes.

There is one other mental health advocate on the committee, Adrienne Ellis, and she knows even more about parity compliance than I do. She is the one person in Maryland who receives complaints from patients and providers about possible parity act violations. Working for the Mental Health Association of Maryland, she investigates complaints and takes action be passing them on to the state Insurance Commissioner, to the U.S. Department of Labor, and to the U.S. Department of Health and Human Services.

We may also need to determine what the minimum level of benefit is for each “metal level.” Metal, as in bronze, silver, gold, and platinum. People will be able to purchase plans that have higher levels of coverage for a higher premium. How we do that is not yet clear.

We also have to address health disparities. This often refers to the barriers that prevent minorities from receiving good health care, but it can also be interpreted to address barriers that people with mental illness have in accessing somatic care. We know that people with chronic mental illness have a foreshortened life span – some dying as much as 25 years earlier. Now, that’s a disparity.

Another aspect that our committee will address is network adequacy. There needs to be a mechanism for people looking at plans to determine if there are enough providers in the area to meet their needs. Health plans have a history of not doing a good job in this department, especially in behavioral health.

A couple years ago, I was helping a patient in the emergency department find a mental health provider. There were 27 providers listed in her online provider directory. I called every single one. Two were able to see her. The rest were either no longer practicing, wrong number, no answer, no longer accepting patients from that payor, or only treated inpatients. And one was deceased.

A 2007 study from the Maryland Psychological Association found that, of the 909 phone calls to mental health providers in health plan directories, 44% were unreachable. Only 161 gave answers about appointment availability. The worst plan, Blue Cross & Blue Shield, took an average of 38 days for an adult patient to be seen during the day, according to the study. Most people would not call this an adequate network.

I am hoping to get measures put in place that automatically monitor for adequate network coverage. For example, a plan can take claims data by provider and indicate next to each provider’s name the number of outpatient claims for initial visits received over the most recently available 12-month period. If you never accept new patients for that payor, the number would be zero. Thus, a patient wouldn’t bother calling that provider. A directory that has mostly zeroes would indicate an inadequate network, and thus someone looking for a plan might want to skip that one. This is called transparency, and I hope this committee will support it.

Did I mention the time frame for making all these decisions?

End of June.

2012!

I truly hope we can complete this task and do a good job. I question our ability to do so, but I know we will do our best.

For those of you in other states, I strongly recommend that you google “[state] health benefit exchange” to discover what your state’s process is for designing these exchange plans. Find the planning website for it. Learn the meeting schedule. Attend, speak up, send them public comments, make noise. If not, you and your patients will pay the price later.

—Steven Roy Daviss, M.D., DFAPA

DR. DAVISS is chair of the department of psychiatry at the University of Maryland’s Baltimore Washington Medical Center, chair of the APA Committee on Electronic Health Records, co-chair of the CCHIT Behavioral Health Work Group, and co-author of Shrink Rap: Three Psychiatrists Explain Their Work, published by Johns Hopkins University Press. In addition to @HITshrink on Twitter, he can be found at [email protected], and on the Shrink Rap blog.

You’ve probably read something about the Health Benefit Exchange (HBE) system that comes out of the Accountable Care Act (ACA). At the time I’m writing this, the Supreme Court has yet to render its opinion about the ACA’s constitutionality. But the Health Benefit Exchange is intended to be a marketplace for insurance plans that meet certain rules and have certain minimal essential health benefits, referred to as Qualified Health Plans or QHPs.

Every state is deciding whether or not to implement an HBE; most of them are, especially given the fact that the federal government will fund 90% of the cost for the first 2 years – seed money, if you will, for the states to get this up and running. Afterward, the cost-sharing reverts back to what it is for all Medicaid recipients, with the feds paying around 40-50% of the Medicaid costs.

I am on one of the advisory committees for Maryland’s HBE, and we just had our first meeting. This is the Plan Management Committee, whose purpose is to collect state-specific perspectives from key stakeholders to inform policy decisions to ensure that the Exchange meets the needs of Maryland residents.

Specifically, we are being asked to be sure that we have sufficient rules in place to ensure that the plans meet federal and state requirements for “qualified plans.” We are also being asked to comment on the following areas and questions:

• Plan Certification, Recertification & Decertification Standards                          What certification, recertification and decertification rules should be adopted?                                                                                                         Should the Exchange require a standardized plan to be offered at each metal level? 

• Health Disparity Reduction                                                                              How can certification standards be used to reduce disparities?

• Pricing of Dental & Vision Plans                                                                     How should dental and vision plan pricing be presented to consumers     to balance accessibility and affordability?

• Plan Choice Architecture                                                                                   How can plan information be presented to best assist consumers to          choose a plan on criteria other than price?

              Should Maryland limit the number of qualified plans issuers can submit               to the Exchange?

If you have not stopped reading this column yet, you are probably asking what any of this has to do with psychiatry. Everything.

These plans need to be in place by 2014, but the rules about what they need to look like and what services they offer need to be developed now. Qualified plans will need to satisfy the Mental Health Parity and Addiction Equity Act, but there is still a lot of confusion about what that means.

Despite this Act becoming law in 2008, there are still no final regulations about how plans can ensure compliance. And, it is starting to look like we won’t see final regulations until after 2014. So, it is important to have stakeholders at these meetings to ensure that they get it right. I attend the meetings, holding my mental health stake, hoping that I can get it right.

That first bullet, about Certification, means the group of 20 or so stakeholders at this meeting must learn about the federal and state law about what the certification standards are, and be sure that we make recommendations to ensure that HBE plans are compliant. I know this includes compliance with the parity law and will come prepared to explain that when the time comes.

There is one other mental health advocate on the committee, Adrienne Ellis, and she knows even more about parity compliance than I do. She is the one person in Maryland who receives complaints from patients and providers about possible parity act violations. Working for the Mental Health Association of Maryland, she investigates complaints and takes action be passing them on to the state Insurance Commissioner, to the U.S. Department of Labor, and to the U.S. Department of Health and Human Services.

We may also need to determine what the minimum level of benefit is for each “metal level.” Metal, as in bronze, silver, gold, and platinum. People will be able to purchase plans that have higher levels of coverage for a higher premium. How we do that is not yet clear.

We also have to address health disparities. This often refers to the barriers that prevent minorities from receiving good health care, but it can also be interpreted to address barriers that people with mental illness have in accessing somatic care. We know that people with chronic mental illness have a foreshortened life span – some dying as much as 25 years earlier. Now, that’s a disparity.

Another aspect that our committee will address is network adequacy. There needs to be a mechanism for people looking at plans to determine if there are enough providers in the area to meet their needs. Health plans have a history of not doing a good job in this department, especially in behavioral health.

A couple years ago, I was helping a patient in the emergency department find a mental health provider. There were 27 providers listed in her online provider directory. I called every single one. Two were able to see her. The rest were either no longer practicing, wrong number, no answer, no longer accepting patients from that payor, or only treated inpatients. And one was deceased.

A 2007 study from the Maryland Psychological Association found that, of the 909 phone calls to mental health providers in health plan directories, 44% were unreachable. Only 161 gave answers about appointment availability. The worst plan, Blue Cross & Blue Shield, took an average of 38 days for an adult patient to be seen during the day, according to the study. Most people would not call this an adequate network.

I am hoping to get measures put in place that automatically monitor for adequate network coverage. For example, a plan can take claims data by provider and indicate next to each provider’s name the number of outpatient claims for initial visits received over the most recently available 12-month period. If you never accept new patients for that payor, the number would be zero. Thus, a patient wouldn’t bother calling that provider. A directory that has mostly zeroes would indicate an inadequate network, and thus someone looking for a plan might want to skip that one. This is called transparency, and I hope this committee will support it.

Did I mention the time frame for making all these decisions?

End of June.

2012!

I truly hope we can complete this task and do a good job. I question our ability to do so, but I know we will do our best.

For those of you in other states, I strongly recommend that you google “[state] health benefit exchange” to discover what your state’s process is for designing these exchange plans. Find the planning website for it. Learn the meeting schedule. Attend, speak up, send them public comments, make noise. If not, you and your patients will pay the price later.

—Steven Roy Daviss, M.D., DFAPA

DR. DAVISS is chair of the department of psychiatry at the University of Maryland’s Baltimore Washington Medical Center, chair of the APA Committee on Electronic Health Records, co-chair of the CCHIT Behavioral Health Work Group, and co-author of Shrink Rap: Three Psychiatrists Explain Their Work, published by Johns Hopkins University Press. In addition to @HITshrink on Twitter, he can be found at [email protected], and on the Shrink Rap blog.

You’ve probably read something about the Health Benefit Exchange (HBE) system that comes out of the Accountable Care Act (ACA). At the time I’m writing this, the Supreme Court has yet to render its opinion about the ACA’s constitutionality. But the Health Benefit Exchange is intended to be a marketplace for insurance plans that meet certain rules and have certain minimal essential health benefits, referred to as Qualified Health Plans or QHPs.

Every state is deciding whether or not to implement an HBE; most of them are, especially given the fact that the federal government will fund 90% of the cost for the first 2 years – seed money, if you will, for the states to get this up and running. Afterward, the cost-sharing reverts back to what it is for all Medicaid recipients, with the feds paying around 40-50% of the Medicaid costs.

I am on one of the advisory committees for Maryland’s HBE, and we just had our first meeting. This is the Plan Management Committee, whose purpose is to collect state-specific perspectives from key stakeholders to inform policy decisions to ensure that the Exchange meets the needs of Maryland residents.

Specifically, we are being asked to be sure that we have sufficient rules in place to ensure that the plans meet federal and state requirements for “qualified plans.” We are also being asked to comment on the following areas and questions:

• Plan Certification, Recertification & Decertification Standards                          What certification, recertification and decertification rules should be adopted?                                                                                                         Should the Exchange require a standardized plan to be offered at each metal level? 

• Health Disparity Reduction                                                                              How can certification standards be used to reduce disparities?

• Pricing of Dental & Vision Plans                                                                     How should dental and vision plan pricing be presented to consumers     to balance accessibility and affordability?

• Plan Choice Architecture                                                                                   How can plan information be presented to best assist consumers to          choose a plan on criteria other than price?

              Should Maryland limit the number of qualified plans issuers can submit               to the Exchange?

If you have not stopped reading this column yet, you are probably asking what any of this has to do with psychiatry. Everything.

These plans need to be in place by 2014, but the rules about what they need to look like and what services they offer need to be developed now. Qualified plans will need to satisfy the Mental Health Parity and Addiction Equity Act, but there is still a lot of confusion about what that means.

Despite this Act becoming law in 2008, there are still no final regulations about how plans can ensure compliance. And, it is starting to look like we won’t see final regulations until after 2014. So, it is important to have stakeholders at these meetings to ensure that they get it right. I attend the meetings, holding my mental health stake, hoping that I can get it right.

That first bullet, about Certification, means the group of 20 or so stakeholders at this meeting must learn about the federal and state law about what the certification standards are, and be sure that we make recommendations to ensure that HBE plans are compliant. I know this includes compliance with the parity law and will come prepared to explain that when the time comes.

There is one other mental health advocate on the committee, Adrienne Ellis, and she knows even more about parity compliance than I do. She is the one person in Maryland who receives complaints from patients and providers about possible parity act violations. Working for the Mental Health Association of Maryland, she investigates complaints and takes action be passing them on to the state Insurance Commissioner, to the U.S. Department of Labor, and to the U.S. Department of Health and Human Services.

We may also need to determine what the minimum level of benefit is for each “metal level.” Metal, as in bronze, silver, gold, and platinum. People will be able to purchase plans that have higher levels of coverage for a higher premium. How we do that is not yet clear.

We also have to address health disparities. This often refers to the barriers that prevent minorities from receiving good health care, but it can also be interpreted to address barriers that people with mental illness have in accessing somatic care. We know that people with chronic mental illness have a foreshortened life span – some dying as much as 25 years earlier. Now, that’s a disparity.

Another aspect that our committee will address is network adequacy. There needs to be a mechanism for people looking at plans to determine if there are enough providers in the area to meet their needs. Health plans have a history of not doing a good job in this department, especially in behavioral health.

A couple years ago, I was helping a patient in the emergency department find a mental health provider. There were 27 providers listed in her online provider directory. I called every single one. Two were able to see her. The rest were either no longer practicing, wrong number, no answer, no longer accepting patients from that payor, or only treated inpatients. And one was deceased.

A 2007 study from the Maryland Psychological Association found that, of the 909 phone calls to mental health providers in health plan directories, 44% were unreachable. Only 161 gave answers about appointment availability. The worst plan, Blue Cross & Blue Shield, took an average of 38 days for an adult patient to be seen during the day, according to the study. Most people would not call this an adequate network.

I am hoping to get measures put in place that automatically monitor for adequate network coverage. For example, a plan can take claims data by provider and indicate next to each provider’s name the number of outpatient claims for initial visits received over the most recently available 12-month period. If you never accept new patients for that payor, the number would be zero. Thus, a patient wouldn’t bother calling that provider. A directory that has mostly zeroes would indicate an inadequate network, and thus someone looking for a plan might want to skip that one. This is called transparency, and I hope this committee will support it.

Did I mention the time frame for making all these decisions?

End of June.

2012!

I truly hope we can complete this task and do a good job. I question our ability to do so, but I know we will do our best.

For those of you in other states, I strongly recommend that you google “[state] health benefit exchange” to discover what your state’s process is for designing these exchange plans. Find the planning website for it. Learn the meeting schedule. Attend, speak up, send them public comments, make noise. If not, you and your patients will pay the price later.

—Steven Roy Daviss, M.D., DFAPA

DR. DAVISS is chair of the department of psychiatry at the University of Maryland’s Baltimore Washington Medical Center, chair of the APA Committee on Electronic Health Records, co-chair of the CCHIT Behavioral Health Work Group, and co-author of Shrink Rap: Three Psychiatrists Explain Their Work, published by Johns Hopkins University Press. In addition to @HITshrink on Twitter, he can be found at [email protected], and on the Shrink Rap blog.

The following hypothetical situation will be familiar to many psychiatrists working in jail setting:

You're in your clinic when you get an urgent call from a duty lieutenant. He has received an order from a judge that a newly received detainee must be evaluated promptly for suicide risk. The order mandates that the inmate be admitted to the jail infirmary, and further commands the jail psychiatrist to continue the specific combination of medications, at specific doses, that were being prescribed in free society.

You do the evaluation and discover the inmate made a rash and impulsive suicide reference in front of the judge, but that he did not intend to kill himself and had several protective factors in his favor. He did not require admission and was willing to participate in outpatient treatment within the facility. Although he arrived with several bottles of medication, none could be administered due to an institutional policy barring the dispensation of medication brought in from free society. Even without this prohibition, at least one of the medications was medically contraindicated due to the inmate's concurrent medical conditions.

You call the duty lieutenant back and advise him about the results of your evaluation.

That's when chaos breaks loose. The lieutenant refuses to house the inmate in general population because the judge ordered admission to the jail's psychiatric infirmary. If you admit the inmate, he will take up the last remaining bed. Furthermore, the infirmary nurse insists that only the free society medicine can be dispensed, against your orders and medical advice, because that's what the judge required.

There are many valid reasons why a judge would write an order like this. Obviously, there was a concern about suicide risk that the court wanted addressed. The inmate had a known psychiatric disorder and the court wanted to ensure that treatment would be provided. An order specifying a dose and frequency of medication could be written merely to ensure that medical information is transmitted to the facility. Nevertheless, the unintended consequences of an order like this are significant.

Occasionally, an inmate may convince a judge that only a court order will ensure that the “correct” medication will be prescribed, usually a medication which has economic value or abuse potential such as chlorpromazine, hydroxyzine, amitriptyline or other tricyclics, bupropion, quetiapine or even controlled substances like opioids or benzodiazepines.

When facing this situation for the first time a new correctional clinician may fear malpractice liability or being found in contempt of court. If the physician is employed by a private contractor, there may be implicit pressure to “keep the peace” and abide by the order, to maintain cordial business relations with the correctional client. The challenge for the correctional clinician is to respect the intent of the order--to perform an evaluation and offer treatment--while retaining one's independent medical judgment.

From an ethical standpoint, clinicians are bound to act in the patient's best interests under the principle of non-malfeasance. Ideally, the clinician acts in conjunction with a cooperative patient to outline available treatment options and alternatives for the patient, who then makes a treatment choice based upon his own values and wishes. Thus, non-malfeasance is balanced with respect for patient autonomy. In correctional work, one must sometimes care for patients who lack regard for their own safety and demand inappropriate or risky interventions. In this case, the ethical imperative of non-malfeasance must take priority.

Also, the principle of equivalence comes into play when an inappropriate order requires a clinician to use a scarce resource, such as an infirmary bed, in a way that would deny that resource to a more needy patient. Equivalence requires physicians to ensure that treatment resources are available for all, prioritized by patient need.

So how should a correctional psychiatrist respond to an unreasonable court order?

After exercising reasonable care and consideration, write a response to the court order and forward it through your administrative chain of command. The response should outline the reason for the evaluation, the clinical information that was available at the time of the evaluation and the pertinent information gathered from the patient interview. The response should document any treatment recommendations that were made along with the rationale behind the treatment decision, or the rationale behind any court-ordered treatments that were considered but rejected. If the inmate is demanding an inappropriate intervention, the response should document in detail any potential harms that could arise from that treatment.

While a situation like this is inherently uncomfortable and controversial, it's important to see it as an opportunity to provide thoughtful feedback to the court and to open a potentially beneficial collaboration. In future cases, a judge who knows the jail psychiatrist can be trusted to respond to a request for an evaluation and to provide competent care will be much less likely to write an unreasonable order. The court can also be a potential ally by reinforcing the rationale behind a treatment decision if an inmate complains or objects.

The American Medical Association's Code of Medical Ethics can also serve as a supporting document. The Code encourages physicians to act in the best interests of patients when making decisions about allocation of resources, and to refrain from treatments that are either unnecessary or futile.

Dr. Hanson is a forensic psychiatrist and co-author of Shrink Rap: Three Psychiatrists Explain Their Work. The opinions expressed are those of the author only, and do not represent those of any of Dr. Hanson's employers or consultees, including the Maryland Department of Health and Mental Hygiene or the Maryland Division of Correction.

The following hypothetical situation will be familiar to many psychiatrists working in jail setting:

You're in your clinic when you get an urgent call from a duty lieutenant. He has received an order from a judge that a newly received detainee must be evaluated promptly for suicide risk. The order mandates that the inmate be admitted to the jail infirmary, and further commands the jail psychiatrist to continue the specific combination of medications, at specific doses, that were being prescribed in free society.

You do the evaluation and discover the inmate made a rash and impulsive suicide reference in front of the judge, but that he did not intend to kill himself and had several protective factors in his favor. He did not require admission and was willing to participate in outpatient treatment within the facility. Although he arrived with several bottles of medication, none could be administered due to an institutional policy barring the dispensation of medication brought in from free society. Even without this prohibition, at least one of the medications was medically contraindicated due to the inmate's concurrent medical conditions.

You call the duty lieutenant back and advise him about the results of your evaluation.

That's when chaos breaks loose. The lieutenant refuses to house the inmate in general population because the judge ordered admission to the jail's psychiatric infirmary. If you admit the inmate, he will take up the last remaining bed. Furthermore, the infirmary nurse insists that only the free society medicine can be dispensed, against your orders and medical advice, because that's what the judge required.

There are many valid reasons why a judge would write an order like this. Obviously, there was a concern about suicide risk that the court wanted addressed. The inmate had a known psychiatric disorder and the court wanted to ensure that treatment would be provided. An order specifying a dose and frequency of medication could be written merely to ensure that medical information is transmitted to the facility. Nevertheless, the unintended consequences of an order like this are significant.

Occasionally, an inmate may convince a judge that only a court order will ensure that the “correct” medication will be prescribed, usually a medication which has economic value or abuse potential such as chlorpromazine, hydroxyzine, amitriptyline or other tricyclics, bupropion, quetiapine or even controlled substances like opioids or benzodiazepines.

When facing this situation for the first time a new correctional clinician may fear malpractice liability or being found in contempt of court. If the physician is employed by a private contractor, there may be implicit pressure to “keep the peace” and abide by the order, to maintain cordial business relations with the correctional client. The challenge for the correctional clinician is to respect the intent of the order--to perform an evaluation and offer treatment--while retaining one's independent medical judgment.

From an ethical standpoint, clinicians are bound to act in the patient's best interests under the principle of non-malfeasance. Ideally, the clinician acts in conjunction with a cooperative patient to outline available treatment options and alternatives for the patient, who then makes a treatment choice based upon his own values and wishes. Thus, non-malfeasance is balanced with respect for patient autonomy. In correctional work, one must sometimes care for patients who lack regard for their own safety and demand inappropriate or risky interventions. In this case, the ethical imperative of non-malfeasance must take priority.

Also, the principle of equivalence comes into play when an inappropriate order requires a clinician to use a scarce resource, such as an infirmary bed, in a way that would deny that resource to a more needy patient. Equivalence requires physicians to ensure that treatment resources are available for all, prioritized by patient need.

So how should a correctional psychiatrist respond to an unreasonable court order?

After exercising reasonable care and consideration, write a response to the court order and forward it through your administrative chain of command. The response should outline the reason for the evaluation, the clinical information that was available at the time of the evaluation and the pertinent information gathered from the patient interview. The response should document any treatment recommendations that were made along with the rationale behind the treatment decision, or the rationale behind any court-ordered treatments that were considered but rejected. If the inmate is demanding an inappropriate intervention, the response should document in detail any potential harms that could arise from that treatment.

While a situation like this is inherently uncomfortable and controversial, it's important to see it as an opportunity to provide thoughtful feedback to the court and to open a potentially beneficial collaboration. In future cases, a judge who knows the jail psychiatrist can be trusted to respond to a request for an evaluation and to provide competent care will be much less likely to write an unreasonable order. The court can also be a potential ally by reinforcing the rationale behind a treatment decision if an inmate complains or objects.

The American Medical Association's Code of Medical Ethics can also serve as a supporting document. The Code encourages physicians to act in the best interests of patients when making decisions about allocation of resources, and to refrain from treatments that are either unnecessary or futile.

Dr. Hanson is a forensic psychiatrist and co-author of Shrink Rap: Three Psychiatrists Explain Their Work. The opinions expressed are those of the author only, and do not represent those of any of Dr. Hanson's employers or consultees, including the Maryland Department of Health and Mental Hygiene or the Maryland Division of Correction.

The following hypothetical situation will be familiar to many psychiatrists working in jail setting:

You're in your clinic when you get an urgent call from a duty lieutenant. He has received an order from a judge that a newly received detainee must be evaluated promptly for suicide risk. The order mandates that the inmate be admitted to the jail infirmary, and further commands the jail psychiatrist to continue the specific combination of medications, at specific doses, that were being prescribed in free society.

You do the evaluation and discover the inmate made a rash and impulsive suicide reference in front of the judge, but that he did not intend to kill himself and had several protective factors in his favor. He did not require admission and was willing to participate in outpatient treatment within the facility. Although he arrived with several bottles of medication, none could be administered due to an institutional policy barring the dispensation of medication brought in from free society. Even without this prohibition, at least one of the medications was medically contraindicated due to the inmate's concurrent medical conditions.

You call the duty lieutenant back and advise him about the results of your evaluation.

That's when chaos breaks loose. The lieutenant refuses to house the inmate in general population because the judge ordered admission to the jail's psychiatric infirmary. If you admit the inmate, he will take up the last remaining bed. Furthermore, the infirmary nurse insists that only the free society medicine can be dispensed, against your orders and medical advice, because that's what the judge required.

There are many valid reasons why a judge would write an order like this. Obviously, there was a concern about suicide risk that the court wanted addressed. The inmate had a known psychiatric disorder and the court wanted to ensure that treatment would be provided. An order specifying a dose and frequency of medication could be written merely to ensure that medical information is transmitted to the facility. Nevertheless, the unintended consequences of an order like this are significant.

Occasionally, an inmate may convince a judge that only a court order will ensure that the “correct” medication will be prescribed, usually a medication which has economic value or abuse potential such as chlorpromazine, hydroxyzine, amitriptyline or other tricyclics, bupropion, quetiapine or even controlled substances like opioids or benzodiazepines.

When facing this situation for the first time a new correctional clinician may fear malpractice liability or being found in contempt of court. If the physician is employed by a private contractor, there may be implicit pressure to “keep the peace” and abide by the order, to maintain cordial business relations with the correctional client. The challenge for the correctional clinician is to respect the intent of the order--to perform an evaluation and offer treatment--while retaining one's independent medical judgment.

From an ethical standpoint, clinicians are bound to act in the patient's best interests under the principle of non-malfeasance. Ideally, the clinician acts in conjunction with a cooperative patient to outline available treatment options and alternatives for the patient, who then makes a treatment choice based upon his own values and wishes. Thus, non-malfeasance is balanced with respect for patient autonomy. In correctional work, one must sometimes care for patients who lack regard for their own safety and demand inappropriate or risky interventions. In this case, the ethical imperative of non-malfeasance must take priority.

Also, the principle of equivalence comes into play when an inappropriate order requires a clinician to use a scarce resource, such as an infirmary bed, in a way that would deny that resource to a more needy patient. Equivalence requires physicians to ensure that treatment resources are available for all, prioritized by patient need.

So how should a correctional psychiatrist respond to an unreasonable court order?

After exercising reasonable care and consideration, write a response to the court order and forward it through your administrative chain of command. The response should outline the reason for the evaluation, the clinical information that was available at the time of the evaluation and the pertinent information gathered from the patient interview. The response should document any treatment recommendations that were made along with the rationale behind the treatment decision, or the rationale behind any court-ordered treatments that were considered but rejected. If the inmate is demanding an inappropriate intervention, the response should document in detail any potential harms that could arise from that treatment.

While a situation like this is inherently uncomfortable and controversial, it's important to see it as an opportunity to provide thoughtful feedback to the court and to open a potentially beneficial collaboration. In future cases, a judge who knows the jail psychiatrist can be trusted to respond to a request for an evaluation and to provide competent care will be much less likely to write an unreasonable order. The court can also be a potential ally by reinforcing the rationale behind a treatment decision if an inmate complains or objects.

The American Medical Association's Code of Medical Ethics can also serve as a supporting document. The Code encourages physicians to act in the best interests of patients when making decisions about allocation of resources, and to refrain from treatments that are either unnecessary or futile.

Dr. Hanson is a forensic psychiatrist and co-author of Shrink Rap: Three Psychiatrists Explain Their Work. The opinions expressed are those of the author only, and do not represent those of any of Dr. Hanson's employers or consultees, including the Maryland Department of Health and Mental Hygiene or the Maryland Division of Correction.

Periodically, I Google myself and check to see what’s on the first few pages of the Google search results. I do this because I assume that patients, and particularly new patients, Google their doctors. Some tell me they do, and one patient said she decided I must be okay because she had read a review I had written on Amazon, and since we liked the same novel, I couldn’t be too bad. Usually, the search results reveal predictable results: They lead people to my books or articles I’ve written, or to the exploits of the other Dinah Millers of the world (there are, in fact, a few of us).

A few weeks ago, I Googled myself to find a surprise: at the top of the first page of search results, there was my name and a one-star notation from the HealthGrades.com website.  I clicked on it to learn that my practice had been reviewed and, across the board, I was a lousy psychiatrist, a single-star (out of a possible 5 stars) in all aspects of my practice, never to be recommended to friends, with an average wait time exceeding 45 minutes. The listed information listed by HealthGrades included my age, an incorrect address with an offer to map directions for the reader, my educational and training background, an incorrect list of insurance panels with whom I participate, and the fact that there are no sanctions or lawsuits against me. I may be a one-star doc, but at the bottom of my page the site lists three 5-star doctors – in case a prospective patient wants to do better?  The first doctor is a familiar name, but I’m a psychiatrist and he’s an oncologist. I didn’t realize we were interchangeable.

I surfed around the HealthGrades site and plugged in my specialty and the city where I live. The first doctor on their list moved to Texas two years ago.  Some of those listed have moved, some are not psychiatrists, and a few are dead. Of the 350 names I perused, few have any ratings at all, and of those who do, most have a single 5-star review. I am the lone one-star psychiatrist in my major metropolitan area.

At first, I didn’t care, but as the days went by, it started to eat at me. I didn’t believe this was written by a patient – I’m not aware of any vindictive patients and the things that are reported are simply not true.  It’s not difficult to get an appointment with me and I don’t spend too little time with patients – I give all patients my cell and home phone numbers before they come in for the initial, two-hour evaluation.  My staff isn’t discourteous or unfriendly: I don’t have a staff.  And in 20 years, I can’t ever recall running more than 10 minutes late, and I generally start right on time.  

Our Shrink Rap blog has, at times, attracted readers who feel injured by psychiatrists and psychotropic medications, and our editorial in the Baltimore Sun opposing legislation to legalize medical marijuana did nothing for my popularity in cyberspace. I assumed the reviewer might be related to the person who posted a one-star review of our Shrink Rap book on Amazon before the book was even released. If the rating was on the HealthGrades website alone, I would never have known about it, but anyone who Googles my name is led straight to the one-star rating.

I asked around and I was told there was nothing to do, no one pays attention to these things, and I shouldn’t worry about it. I e-mailed Kevin Pho, the creator of the KevinMD medical blog, who is working on a book about physicians’ online reputations.  

Dr. Pho replied: “The prospect of having an online presence is a frightening proposition for many physicians.  But if they don't proactively define themselves online, someone else is going to do it for them.  An online reputation is just as important as a reputation within the community.  Doctors should use social media profiles, like a LinkedIn profile or Facebook page, to create their own digital footprint with information they create and control.”

I already have a digital footprint, and HealthGrades seems to trump whatever that might be, so I decided to contact the company and ask that they investigate on the grounds that I did not believe this was a valid patient review.  I sent an e-mail, and filled in the same information on their contact sheet.  I followed up with another e-mail the next day, and five days later, I called HealthGrades.

HealthGrades is an Internet company, founded in 1995, with a mission to improve health care by rating hospitals, specialties, and procedures.  Its annual revenues exceed $27 million a year. Providing an open venue for Internet users to rate physicians is only a small part of what they do.
     
I spoke with an investigator at HealthGrades on May 21, 2012.  He said an investigation was underway and would could take up to 10 business days.  I asked for the email address of the person who had written the review and was told that could not be released because of confidentiality.  Wait, an anonymous person who may never have met me is permitted to potentially harm both my professional reputation and even my income, and they are entitled to “confidentiality,” with no requirement to prove they have been my patient? 

I asked the investigator to please contact the reviewer and, if in fact it was a disgruntled patient, to tell the patient I would like to meet with them at no fee, of course, so I could learn what I was doing wrong in my practice of psychiatry.  I also asked, repeatedly, for a list of procedures that are taken when a physician requests and investigation, and I was told that these, too, are “confidential.”  
     
Three days later, I called again and was told that because I was in the behavioral health field, my review would be removed in 24 to 48 hours, but that HealthGrades has nothing to do with Google and it could take 30 days before the Google search stopped announcing my professional inadequacy. An e-mail I received said the review would be removed in 14 business days, but it was, in fact, removed within a day.  
   
MacLean Guthrie, vice president of public communications/corporate communications for HealthGrades explained, “We have a policy of removing patient surveys submitted for mental health professionals because this conflicts with the ethical responsibilities and constraints for behavioral health providers and their clients. As such, we’re removing the survey submitted to your profile from our site.”  There is nothing on their website that indicates this, but I was happy to have my single star vanish, at least until it happens again.  I don’t imagine 5-star reviews prompt many complaints, so the rating of psychiatrists is oddly skewed in favor of the doctor, and perhaps this explains why I was the only 1-star psychiatrist among the list I reviewed.   
   
So HealthGrades never asked if I wanted to be listed on their website; my information appears there, much of it incorrect, without my permission or consent.  

Before I hung up from my first phone call to HealthGrades, I asked the investigator his name.

    “Mike.”

    “And your last name?”

     “We aren’t permitted to release that,” Mike told me.  Yet another ironic policy for a company that, according to its founder, Kerry Hicks,  “ is built on the principles of transparency, provider accountability, and consumer empowerment.”  I had to wonder, was Mike worried that someone might say negative things about him online?
     
—Dinah Miller

Please note that Vitals.com and RateMDs.com also provide similar venues for public comment on physician practices.  They were not the topic of this article simply because they didn’t show up on my Google search page with a one-star review.  

As of this morning, HealthGrades has also honored my request to remove my information from its site.

If you would like to comment on this article here, please register with CLINICAL PSYCHIATRY NEWS. If you are already registered, please log in to comment.

If you would like to comment on this topic on Shrink Rap, please click here to read more about the topic on that website.   

DR. MILLER is the co-author of Shrink Rap: Three Psychiatrists Explain Their Work, published by Johns Hopkins University Press.

Periodically, I Google myself and check to see what’s on the first few pages of the Google search results. I do this because I assume that patients, and particularly new patients, Google their doctors. Some tell me they do, and one patient said she decided I must be okay because she had read a review I had written on Amazon, and since we liked the same novel, I couldn’t be too bad. Usually, the search results reveal predictable results: They lead people to my books or articles I’ve written, or to the exploits of the other Dinah Millers of the world (there are, in fact, a few of us).

A few weeks ago, I Googled myself to find a surprise: at the top of the first page of search results, there was my name and a one-star notation from the HealthGrades.com website.  I clicked on it to learn that my practice had been reviewed and, across the board, I was a lousy psychiatrist, a single-star (out of a possible 5 stars) in all aspects of my practice, never to be recommended to friends, with an average wait time exceeding 45 minutes. The listed information listed by HealthGrades included my age, an incorrect address with an offer to map directions for the reader, my educational and training background, an incorrect list of insurance panels with whom I participate, and the fact that there are no sanctions or lawsuits against me. I may be a one-star doc, but at the bottom of my page the site lists three 5-star doctors – in case a prospective patient wants to do better?  The first doctor is a familiar name, but I’m a psychiatrist and he’s an oncologist. I didn’t realize we were interchangeable.

I surfed around the HealthGrades site and plugged in my specialty and the city where I live. The first doctor on their list moved to Texas two years ago.  Some of those listed have moved, some are not psychiatrists, and a few are dead. Of the 350 names I perused, few have any ratings at all, and of those who do, most have a single 5-star review. I am the lone one-star psychiatrist in my major metropolitan area.

At first, I didn’t care, but as the days went by, it started to eat at me. I didn’t believe this was written by a patient – I’m not aware of any vindictive patients and the things that are reported are simply not true.  It’s not difficult to get an appointment with me and I don’t spend too little time with patients – I give all patients my cell and home phone numbers before they come in for the initial, two-hour evaluation.  My staff isn’t discourteous or unfriendly: I don’t have a staff.  And in 20 years, I can’t ever recall running more than 10 minutes late, and I generally start right on time.  

Our Shrink Rap blog has, at times, attracted readers who feel injured by psychiatrists and psychotropic medications, and our editorial in the Baltimore Sun opposing legislation to legalize medical marijuana did nothing for my popularity in cyberspace. I assumed the reviewer might be related to the person who posted a one-star review of our Shrink Rap book on Amazon before the book was even released. If the rating was on the HealthGrades website alone, I would never have known about it, but anyone who Googles my name is led straight to the one-star rating.

I asked around and I was told there was nothing to do, no one pays attention to these things, and I shouldn’t worry about it. I e-mailed Kevin Pho, the creator of the KevinMD medical blog, who is working on a book about physicians’ online reputations.  

Dr. Pho replied: “The prospect of having an online presence is a frightening proposition for many physicians.  But if they don't proactively define themselves online, someone else is going to do it for them.  An online reputation is just as important as a reputation within the community.  Doctors should use social media profiles, like a LinkedIn profile or Facebook page, to create their own digital footprint with information they create and control.”

I already have a digital footprint, and HealthGrades seems to trump whatever that might be, so I decided to contact the company and ask that they investigate on the grounds that I did not believe this was a valid patient review.  I sent an e-mail, and filled in the same information on their contact sheet.  I followed up with another e-mail the next day, and five days later, I called HealthGrades.

HealthGrades is an Internet company, founded in 1995, with a mission to improve health care by rating hospitals, specialties, and procedures.  Its annual revenues exceed $27 million a year. Providing an open venue for Internet users to rate physicians is only a small part of what they do.
     
I spoke with an investigator at HealthGrades on May 21, 2012.  He said an investigation was underway and would could take up to 10 business days.  I asked for the email address of the person who had written the review and was told that could not be released because of confidentiality.  Wait, an anonymous person who may never have met me is permitted to potentially harm both my professional reputation and even my income, and they are entitled to “confidentiality,” with no requirement to prove they have been my patient? 

I asked the investigator to please contact the reviewer and, if in fact it was a disgruntled patient, to tell the patient I would like to meet with them at no fee, of course, so I could learn what I was doing wrong in my practice of psychiatry.  I also asked, repeatedly, for a list of procedures that are taken when a physician requests and investigation, and I was told that these, too, are “confidential.”  
     
Three days later, I called again and was told that because I was in the behavioral health field, my review would be removed in 24 to 48 hours, but that HealthGrades has nothing to do with Google and it could take 30 days before the Google search stopped announcing my professional inadequacy. An e-mail I received said the review would be removed in 14 business days, but it was, in fact, removed within a day.  
   
MacLean Guthrie, vice president of public communications/corporate communications for HealthGrades explained, “We have a policy of removing patient surveys submitted for mental health professionals because this conflicts with the ethical responsibilities and constraints for behavioral health providers and their clients. As such, we’re removing the survey submitted to your profile from our site.”  There is nothing on their website that indicates this, but I was happy to have my single star vanish, at least until it happens again.  I don’t imagine 5-star reviews prompt many complaints, so the rating of psychiatrists is oddly skewed in favor of the doctor, and perhaps this explains why I was the only 1-star psychiatrist among the list I reviewed.   
   
So HealthGrades never asked if I wanted to be listed on their website; my information appears there, much of it incorrect, without my permission or consent.  

Before I hung up from my first phone call to HealthGrades, I asked the investigator his name.

    “Mike.”

    “And your last name?”

     “We aren’t permitted to release that,” Mike told me.  Yet another ironic policy for a company that, according to its founder, Kerry Hicks,  “ is built on the principles of transparency, provider accountability, and consumer empowerment.”  I had to wonder, was Mike worried that someone might say negative things about him online?
     
—Dinah Miller

Please note that Vitals.com and RateMDs.com also provide similar venues for public comment on physician practices.  They were not the topic of this article simply because they didn’t show up on my Google search page with a one-star review.  

As of this morning, HealthGrades has also honored my request to remove my information from its site.

If you would like to comment on this article here, please register with CLINICAL PSYCHIATRY NEWS. If you are already registered, please log in to comment.

If you would like to comment on this topic on Shrink Rap, please click here to read more about the topic on that website.   

DR. MILLER is the co-author of Shrink Rap: Three Psychiatrists Explain Their Work, published by Johns Hopkins University Press.

Periodically, I Google myself and check to see what’s on the first few pages of the Google search results. I do this because I assume that patients, and particularly new patients, Google their doctors. Some tell me they do, and one patient said she decided I must be okay because she had read a review I had written on Amazon, and since we liked the same novel, I couldn’t be too bad. Usually, the search results reveal predictable results: They lead people to my books or articles I’ve written, or to the exploits of the other Dinah Millers of the world (there are, in fact, a few of us).

A few weeks ago, I Googled myself to find a surprise: at the top of the first page of search results, there was my name and a one-star notation from the HealthGrades.com website.  I clicked on it to learn that my practice had been reviewed and, across the board, I was a lousy psychiatrist, a single-star (out of a possible 5 stars) in all aspects of my practice, never to be recommended to friends, with an average wait time exceeding 45 minutes. The listed information listed by HealthGrades included my age, an incorrect address with an offer to map directions for the reader, my educational and training background, an incorrect list of insurance panels with whom I participate, and the fact that there are no sanctions or lawsuits against me. I may be a one-star doc, but at the bottom of my page the site lists three 5-star doctors – in case a prospective patient wants to do better?  The first doctor is a familiar name, but I’m a psychiatrist and he’s an oncologist. I didn’t realize we were interchangeable.

I surfed around the HealthGrades site and plugged in my specialty and the city where I live. The first doctor on their list moved to Texas two years ago.  Some of those listed have moved, some are not psychiatrists, and a few are dead. Of the 350 names I perused, few have any ratings at all, and of those who do, most have a single 5-star review. I am the lone one-star psychiatrist in my major metropolitan area.

At first, I didn’t care, but as the days went by, it started to eat at me. I didn’t believe this was written by a patient – I’m not aware of any vindictive patients and the things that are reported are simply not true.  It’s not difficult to get an appointment with me and I don’t spend too little time with patients – I give all patients my cell and home phone numbers before they come in for the initial, two-hour evaluation.  My staff isn’t discourteous or unfriendly: I don’t have a staff.  And in 20 years, I can’t ever recall running more than 10 minutes late, and I generally start right on time.  

Our Shrink Rap blog has, at times, attracted readers who feel injured by psychiatrists and psychotropic medications, and our editorial in the Baltimore Sun opposing legislation to legalize medical marijuana did nothing for my popularity in cyberspace. I assumed the reviewer might be related to the person who posted a one-star review of our Shrink Rap book on Amazon before the book was even released. If the rating was on the HealthGrades website alone, I would never have known about it, but anyone who Googles my name is led straight to the one-star rating.

I asked around and I was told there was nothing to do, no one pays attention to these things, and I shouldn’t worry about it. I e-mailed Kevin Pho, the creator of the KevinMD medical blog, who is working on a book about physicians’ online reputations.  

Dr. Pho replied: “The prospect of having an online presence is a frightening proposition for many physicians.  But if they don't proactively define themselves online, someone else is going to do it for them.  An online reputation is just as important as a reputation within the community.  Doctors should use social media profiles, like a LinkedIn profile or Facebook page, to create their own digital footprint with information they create and control.”

I already have a digital footprint, and HealthGrades seems to trump whatever that might be, so I decided to contact the company and ask that they investigate on the grounds that I did not believe this was a valid patient review.  I sent an e-mail, and filled in the same information on their contact sheet.  I followed up with another e-mail the next day, and five days later, I called HealthGrades.

HealthGrades is an Internet company, founded in 1995, with a mission to improve health care by rating hospitals, specialties, and procedures.  Its annual revenues exceed $27 million a year. Providing an open venue for Internet users to rate physicians is only a small part of what they do.
     
I spoke with an investigator at HealthGrades on May 21, 2012.  He said an investigation was underway and would could take up to 10 business days.  I asked for the email address of the person who had written the review and was told that could not be released because of confidentiality.  Wait, an anonymous person who may never have met me is permitted to potentially harm both my professional reputation and even my income, and they are entitled to “confidentiality,” with no requirement to prove they have been my patient? 

I asked the investigator to please contact the reviewer and, if in fact it was a disgruntled patient, to tell the patient I would like to meet with them at no fee, of course, so I could learn what I was doing wrong in my practice of psychiatry.  I also asked, repeatedly, for a list of procedures that are taken when a physician requests and investigation, and I was told that these, too, are “confidential.”  
     
Three days later, I called again and was told that because I was in the behavioral health field, my review would be removed in 24 to 48 hours, but that HealthGrades has nothing to do with Google and it could take 30 days before the Google search stopped announcing my professional inadequacy. An e-mail I received said the review would be removed in 14 business days, but it was, in fact, removed within a day.  
   
MacLean Guthrie, vice president of public communications/corporate communications for HealthGrades explained, “We have a policy of removing patient surveys submitted for mental health professionals because this conflicts with the ethical responsibilities and constraints for behavioral health providers and their clients. As such, we’re removing the survey submitted to your profile from our site.”  There is nothing on their website that indicates this, but I was happy to have my single star vanish, at least until it happens again.  I don’t imagine 5-star reviews prompt many complaints, so the rating of psychiatrists is oddly skewed in favor of the doctor, and perhaps this explains why I was the only 1-star psychiatrist among the list I reviewed.   
   
So HealthGrades never asked if I wanted to be listed on their website; my information appears there, much of it incorrect, without my permission or consent.  

Before I hung up from my first phone call to HealthGrades, I asked the investigator his name.

    “Mike.”

    “And your last name?”

     “We aren’t permitted to release that,” Mike told me.  Yet another ironic policy for a company that, according to its founder, Kerry Hicks,  “ is built on the principles of transparency, provider accountability, and consumer empowerment.”  I had to wonder, was Mike worried that someone might say negative things about him online?
     
—Dinah Miller

Please note that Vitals.com and RateMDs.com also provide similar venues for public comment on physician practices.  They were not the topic of this article simply because they didn’t show up on my Google search page with a one-star review.  

As of this morning, HealthGrades has also honored my request to remove my information from its site.

If you would like to comment on this article here, please register with CLINICAL PSYCHIATRY NEWS. If you are already registered, please log in to comment.

If you would like to comment on this topic on Shrink Rap, please click here to read more about the topic on that website.   

DR. MILLER is the co-author of Shrink Rap: Three Psychiatrists Explain Their Work, published by Johns Hopkins University Press.

What’s your mental health number?

This is the question that the Bipolar Collaborative is asking, using its M3 screening tool. “Many other illnesses have a 'number' that one can track – cholesterol, high blood pressure, diabetes. What’s the number for mental health?” asks Michael Byer, president of M3 Information, based in Bethesda, Md.

Psychiatrist researcher, Robert Post, started the Bipolar Collaborative almost 10 years ago. “I became frustrated that our field had not made any significant improvements in screening for mental illness, particularly bipolar disorder.” So, the former chief of the NIMH Mood Disorders Branch decided to do something about it and developed, along with a team of other researchers and clinicians, a screening tool that assesses not just depression, but also symptoms of bipolar disorder, PTSD, and other forms of anxiety. [Disclosure: this author is an adviser to M3 Information and has a small stake in the company.]

The 3-minute, 27-item tool was validated at the University of North Carolina. The researchers recruited 647 adult outpatients from an academic primary care practice and compared results on the M3 with those from the Mini International Neuropsychiatric Interview that was used as the gold standard.

The total M3 score demonstrated 0.83 sensitivity and 0.76 specificity for any psychiatric disorder, and similar or better metrics for the four disease components of major depression, bipolar disorder, PTSD, and anxiety disorder.

The clinicians found that they could review the results in under 30 seconds and that it helped them quickly review the patients’ emotional health. “The advantage to WhatsMyM3 over the historical depression screening tool, the PHQ-9, is that the PHQ does not look for bipolar symptoms at all, meaning you will commit a fifth of patients screening positive to the wrong treatment,” said Byer. “It also screens for anxiety disorder, which is often overlooked or masquerades as other conditions.”

Dr. Post’s group has developed a free website, WhatsMyM3.com, where anyone can take the confidential test for free. They have also developed mobile health apps on both iPhone and Android platforms. These “mHealth” apps have the ability to track symptom scores over time, and one can upload the results to Microsoft HealthVault, making it potentially available to your health care provider in their electronic health record.

It is well recognized that mental illnesses are prevalent, often go untreated, and result in heavy personal and societal consequences. The National Comorbidity Survey found a 12-month prevalence estimate of 9.5% for mood disorders, with nearly half being considered severe. Anxiety disorder prevalence was twice as high as mood disorders. And only a little more than one-third were receiving minimally adequate treatment. The World Health Organization has identified depression as the leading contributor of disease burden in the United States and Canada (as measured by disability-adjusted life years or DALYs) – more than ischemic heart disease, stroke, lung cancer, and COPD.

The costs of untreated mental illness are high. Dr. Roger Kathol, from Cartesian Solutions, used claims data to show that the cost of comorbid mental illness in someone with a chronic medical condition, like arthritis, diabetes, and congestive heart failure, is double the cost of having the chronic condition alone. And much of that increased cost falls in the physical health side. Identifying and treating the mental illness results in significant reductions in costs. [1]

“Now that employers recognize the benefits and payers are paying for health risk assessments, such as the M3, using the 99420 CPT code, there is an even greater incentive for primary care providers to screen their patients annually. We built the m3clinician provider portal to facilitate regular screenings and tracking of symptoms over time by a provider,” said Byer.
So, what’s your M3?

—Steven Roy Daviss, M.D., DFAPA

DR. DAVISS is chair of the department of psychiatry at the University of Maryland’s Baltimore Washington Medical Center, chair of the APA Committee on Electronic Health Records, co-chair of the CCHIT Behavioral Health Work Group, and co-author of Shrink Rap: Three Psychiatrists Explain Their Work, published by Johns Hopkins University Press. He is found on Twitter @HITshrink, at drdavissATgmail.com, and on the Shrink Rap blog.

[1] Kathol, 2012. “Psychiatrist Orientation to Health Complexity & Integrated Care Management.” Presentation at the Annual APA Meeting, Philadelphia.

What’s your mental health number?

This is the question that the Bipolar Collaborative is asking, using its M3 screening tool. “Many other illnesses have a 'number' that one can track – cholesterol, high blood pressure, diabetes. What’s the number for mental health?” asks Michael Byer, president of M3 Information, based in Bethesda, Md.

Psychiatrist researcher, Robert Post, started the Bipolar Collaborative almost 10 years ago. “I became frustrated that our field had not made any significant improvements in screening for mental illness, particularly bipolar disorder.” So, the former chief of the NIMH Mood Disorders Branch decided to do something about it and developed, along with a team of other researchers and clinicians, a screening tool that assesses not just depression, but also symptoms of bipolar disorder, PTSD, and other forms of anxiety. [Disclosure: this author is an adviser to M3 Information and has a small stake in the company.]

The 3-minute, 27-item tool was validated at the University of North Carolina. The researchers recruited 647 adult outpatients from an academic primary care practice and compared results on the M3 with those from the Mini International Neuropsychiatric Interview that was used as the gold standard.

The total M3 score demonstrated 0.83 sensitivity and 0.76 specificity for any psychiatric disorder, and similar or better metrics for the four disease components of major depression, bipolar disorder, PTSD, and anxiety disorder.

The clinicians found that they could review the results in under 30 seconds and that it helped them quickly review the patients’ emotional health. “The advantage to WhatsMyM3 over the historical depression screening tool, the PHQ-9, is that the PHQ does not look for bipolar symptoms at all, meaning you will commit a fifth of patients screening positive to the wrong treatment,” said Byer. “It also screens for anxiety disorder, which is often overlooked or masquerades as other conditions.”

Dr. Post’s group has developed a free website, WhatsMyM3.com, where anyone can take the confidential test for free. They have also developed mobile health apps on both iPhone and Android platforms. These “mHealth” apps have the ability to track symptom scores over time, and one can upload the results to Microsoft HealthVault, making it potentially available to your health care provider in their electronic health record.

It is well recognized that mental illnesses are prevalent, often go untreated, and result in heavy personal and societal consequences. The National Comorbidity Survey found a 12-month prevalence estimate of 9.5% for mood disorders, with nearly half being considered severe. Anxiety disorder prevalence was twice as high as mood disorders. And only a little more than one-third were receiving minimally adequate treatment. The World Health Organization has identified depression as the leading contributor of disease burden in the United States and Canada (as measured by disability-adjusted life years or DALYs) – more than ischemic heart disease, stroke, lung cancer, and COPD.

The costs of untreated mental illness are high. Dr. Roger Kathol, from Cartesian Solutions, used claims data to show that the cost of comorbid mental illness in someone with a chronic medical condition, like arthritis, diabetes, and congestive heart failure, is double the cost of having the chronic condition alone. And much of that increased cost falls in the physical health side. Identifying and treating the mental illness results in significant reductions in costs. [1]

“Now that employers recognize the benefits and payers are paying for health risk assessments, such as the M3, using the 99420 CPT code, there is an even greater incentive for primary care providers to screen their patients annually. We built the m3clinician provider portal to facilitate regular screenings and tracking of symptoms over time by a provider,” said Byer.
So, what’s your M3?

—Steven Roy Daviss, M.D., DFAPA

DR. DAVISS is chair of the department of psychiatry at the University of Maryland’s Baltimore Washington Medical Center, chair of the APA Committee on Electronic Health Records, co-chair of the CCHIT Behavioral Health Work Group, and co-author of Shrink Rap: Three Psychiatrists Explain Their Work, published by Johns Hopkins University Press. He is found on Twitter @HITshrink, at drdavissATgmail.com, and on the Shrink Rap blog.

[1] Kathol, 2012. “Psychiatrist Orientation to Health Complexity & Integrated Care Management.” Presentation at the Annual APA Meeting, Philadelphia.

What’s your mental health number?

This is the question that the Bipolar Collaborative is asking, using its M3 screening tool. “Many other illnesses have a 'number' that one can track – cholesterol, high blood pressure, diabetes. What’s the number for mental health?” asks Michael Byer, president of M3 Information, based in Bethesda, Md.

Psychiatrist researcher, Robert Post, started the Bipolar Collaborative almost 10 years ago. “I became frustrated that our field had not made any significant improvements in screening for mental illness, particularly bipolar disorder.” So, the former chief of the NIMH Mood Disorders Branch decided to do something about it and developed, along with a team of other researchers and clinicians, a screening tool that assesses not just depression, but also symptoms of bipolar disorder, PTSD, and other forms of anxiety. [Disclosure: this author is an adviser to M3 Information and has a small stake in the company.]

The 3-minute, 27-item tool was validated at the University of North Carolina. The researchers recruited 647 adult outpatients from an academic primary care practice and compared results on the M3 with those from the Mini International Neuropsychiatric Interview that was used as the gold standard.

The total M3 score demonstrated 0.83 sensitivity and 0.76 specificity for any psychiatric disorder, and similar or better metrics for the four disease components of major depression, bipolar disorder, PTSD, and anxiety disorder.

The clinicians found that they could review the results in under 30 seconds and that it helped them quickly review the patients’ emotional health. “The advantage to WhatsMyM3 over the historical depression screening tool, the PHQ-9, is that the PHQ does not look for bipolar symptoms at all, meaning you will commit a fifth of patients screening positive to the wrong treatment,” said Byer. “It also screens for anxiety disorder, which is often overlooked or masquerades as other conditions.”

Dr. Post’s group has developed a free website, WhatsMyM3.com, where anyone can take the confidential test for free. They have also developed mobile health apps on both iPhone and Android platforms. These “mHealth” apps have the ability to track symptom scores over time, and one can upload the results to Microsoft HealthVault, making it potentially available to your health care provider in their electronic health record.

It is well recognized that mental illnesses are prevalent, often go untreated, and result in heavy personal and societal consequences. The National Comorbidity Survey found a 12-month prevalence estimate of 9.5% for mood disorders, with nearly half being considered severe. Anxiety disorder prevalence was twice as high as mood disorders. And only a little more than one-third were receiving minimally adequate treatment. The World Health Organization has identified depression as the leading contributor of disease burden in the United States and Canada (as measured by disability-adjusted life years or DALYs) – more than ischemic heart disease, stroke, lung cancer, and COPD.

The costs of untreated mental illness are high. Dr. Roger Kathol, from Cartesian Solutions, used claims data to show that the cost of comorbid mental illness in someone with a chronic medical condition, like arthritis, diabetes, and congestive heart failure, is double the cost of having the chronic condition alone. And much of that increased cost falls in the physical health side. Identifying and treating the mental illness results in significant reductions in costs. [1]

“Now that employers recognize the benefits and payers are paying for health risk assessments, such as the M3, using the 99420 CPT code, there is an even greater incentive for primary care providers to screen their patients annually. We built the m3clinician provider portal to facilitate regular screenings and tracking of symptoms over time by a provider,” said Byer.
So, what’s your M3?

—Steven Roy Daviss, M.D., DFAPA

DR. DAVISS is chair of the department of psychiatry at the University of Maryland’s Baltimore Washington Medical Center, chair of the APA Committee on Electronic Health Records, co-chair of the CCHIT Behavioral Health Work Group, and co-author of Shrink Rap: Three Psychiatrists Explain Their Work, published by Johns Hopkins University Press. He is found on Twitter @HITshrink, at drdavissATgmail.com, and on the Shrink Rap blog.

[1] Kathol, 2012. “Psychiatrist Orientation to Health Complexity & Integrated Care Management.” Presentation at the Annual APA Meeting, Philadelphia.

In 1920, a former stable worker and handyman by the name of Harry Crawford was arrested in Australia for the murder of his wife. There was no apparent motive for the murder until Crawford’s daughter revealed that her “father” was actually Italian-born Eugenia Falleni, a woman who had concealed her biological gender throughout the marriage.

The murder was precipitated when the victim discovered Crawford’s deception and threatened to reveal it. The trial and sexual ambiguity of the defendant captivated the early 20th century media and is the first well-documented case of a gender-disordered prisoner. Falleni served 11 years in a women’s prison, living her opposite-gender role.

The Diagnostic and Statistical Manual IV-TR defines gender identity disorder as a strong persistent identification that one is actually the opposite gender. The identification has to be strong enough to cause discomfort with one’s own gender identity and distress or impairment in social and occupational functioning. The prevalence of gender identity disorder in the United States is unknown. The California prison system has estimated that it contains hundreds of transgendered prisoners.

The treatment for gender identity disorder is outlined in the World Professional Association for Transgender Health (WPATH) guidelines. The WPATH guidelines describe three stages of treatment: psychotherapy, two years of living in the cross-gendered role with hormone therapy, and finally sex reassignment surgery. Most treatment for gender identity disorder is not reimbursed by insurance companies.

The correctional environment contains several barriers to compliance with WPATH guidelines. Initially there was controversy about whether gender identity disorder was a medical or a mental health condition, leading to conflicts within the facility regarding which department bore responsibility for treatment.

Many correctional clinicians lacked experience evaluating sexual disorders and had difficulty distinguishing between gender identity disorder and homosexuality. Finally, physicians unfamiliar with hormonal therapy lacked the experience to prescribe and monitor the medication.

Because of these barriers, jails and prisons originally did not offer treatment for the condition. Inmates coming in to a facility on hormonal therapy had their medication discontinued, leading to episodes of depression and self-injury or even genital mutilation.

In the 1990s, individual lawsuits filed by transgendered prisoners led courts to recognize gender identity disorder as a serious medical condition for which treatment was constitutionally mandated. Jails and prisons were required to continue hormone therapy for inmates being treated prior to incarceration, and to provide psychotherapy for the condition and its associated problems. By 2007, 18 states had policies related to transgender inmate health care.

Currently, transgendered inmates are generally recognized as having a right to mental health counseling and hormonal therapy.

In 2003 the Canadian Federal court ruled that transgendered prisoners could not be categorically denied sex reassignment surgery. Across the border, Wisconsin promptly passed Act 105, also known as the “Inmate Sex Change Prevention Act,” which barred the use of prison health care funds for hormone therapy or sex reassignment surgery. The Federal district court ruled the law unconstitutional in the 2010 case Fields v. Smith.(1) The court pointed out that the law blocked physicians from using their professional discretion for treatment decisions. The court also ruled that cost could not be used as an excuse to deny treatment, since the annual cost of hormone therapy was substantially less than the cost of organ transplantation and open heart surgical procedures, which the Wisconsin prison system did provide. Also, hormone therapy costs only $1,000 per inmate per year, less than half the cost of atypical antipsychotic therapy.

Two months ago the U.S. Supreme Court declined review of the case, meaning that now sex reassignment surgery may be provided to prisoners on a case-by-case basis. Presently, individual prison lawsuits for sex reassignment surgery are being pursued in Massachusetts and California.

The National Commission for Correctional Health Care, the agency that accredits jails and prisons, has a position statement regarding the treatment of transgendered prisoners which recommends medical treatment in accordance with WPATH standards, or surgical treatment if indicated on a case-by-case basis.

The correctional management of transgendered inmates is an evolving issue. In addition to changes in policy regarding medical care, some systems working in conjunction with advocacy groups have developed specialized housing units or tiers specifically for these prisoners. Psychiatrists working in correctional facilities should be informed about gender identity disorder in order to be part of an effective clinical treatment team.

—Annette Hanson, M.D.

DR. HANSON is a forensic psychiatrist and co-author of Shrink Rap: Three Psychiatrists Explain Their Work. The opinions expressed are those of the author only, and do not represent those of any of Dr. Hanson’s employers or consultees, including the Maryland Department of Health and Mental Hygiene or the Maryland Division of Correction.

1. Fields v. Smith, 712 F.Supp. 2d 830 (2010)

In 1920, a former stable worker and handyman by the name of Harry Crawford was arrested in Australia for the murder of his wife. There was no apparent motive for the murder until Crawford’s daughter revealed that her “father” was actually Italian-born Eugenia Falleni, a woman who had concealed her biological gender throughout the marriage.

The murder was precipitated when the victim discovered Crawford’s deception and threatened to reveal it. The trial and sexual ambiguity of the defendant captivated the early 20th century media and is the first well-documented case of a gender-disordered prisoner. Falleni served 11 years in a women’s prison, living her opposite-gender role.

The Diagnostic and Statistical Manual IV-TR defines gender identity disorder as a strong persistent identification that one is actually the opposite gender. The identification has to be strong enough to cause discomfort with one’s own gender identity and distress or impairment in social and occupational functioning. The prevalence of gender identity disorder in the United States is unknown. The California prison system has estimated that it contains hundreds of transgendered prisoners.

The treatment for gender identity disorder is outlined in the World Professional Association for Transgender Health (WPATH) guidelines. The WPATH guidelines describe three stages of treatment: psychotherapy, two years of living in the cross-gendered role with hormone therapy, and finally sex reassignment surgery. Most treatment for gender identity disorder is not reimbursed by insurance companies.

The correctional environment contains several barriers to compliance with WPATH guidelines. Initially there was controversy about whether gender identity disorder was a medical or a mental health condition, leading to conflicts within the facility regarding which department bore responsibility for treatment.

Many correctional clinicians lacked experience evaluating sexual disorders and had difficulty distinguishing between gender identity disorder and homosexuality. Finally, physicians unfamiliar with hormonal therapy lacked the experience to prescribe and monitor the medication.

Because of these barriers, jails and prisons originally did not offer treatment for the condition. Inmates coming in to a facility on hormonal therapy had their medication discontinued, leading to episodes of depression and self-injury or even genital mutilation.

In the 1990s, individual lawsuits filed by transgendered prisoners led courts to recognize gender identity disorder as a serious medical condition for which treatment was constitutionally mandated. Jails and prisons were required to continue hormone therapy for inmates being treated prior to incarceration, and to provide psychotherapy for the condition and its associated problems. By 2007, 18 states had policies related to transgender inmate health care.

Currently, transgendered inmates are generally recognized as having a right to mental health counseling and hormonal therapy.

In 2003 the Canadian Federal court ruled that transgendered prisoners could not be categorically denied sex reassignment surgery. Across the border, Wisconsin promptly passed Act 105, also known as the “Inmate Sex Change Prevention Act,” which barred the use of prison health care funds for hormone therapy or sex reassignment surgery. The Federal district court ruled the law unconstitutional in the 2010 case Fields v. Smith.(1) The court pointed out that the law blocked physicians from using their professional discretion for treatment decisions. The court also ruled that cost could not be used as an excuse to deny treatment, since the annual cost of hormone therapy was substantially less than the cost of organ transplantation and open heart surgical procedures, which the Wisconsin prison system did provide. Also, hormone therapy costs only $1,000 per inmate per year, less than half the cost of atypical antipsychotic therapy.

Two months ago the U.S. Supreme Court declined review of the case, meaning that now sex reassignment surgery may be provided to prisoners on a case-by-case basis. Presently, individual prison lawsuits for sex reassignment surgery are being pursued in Massachusetts and California.

The National Commission for Correctional Health Care, the agency that accredits jails and prisons, has a position statement regarding the treatment of transgendered prisoners which recommends medical treatment in accordance with WPATH standards, or surgical treatment if indicated on a case-by-case basis.

The correctional management of transgendered inmates is an evolving issue. In addition to changes in policy regarding medical care, some systems working in conjunction with advocacy groups have developed specialized housing units or tiers specifically for these prisoners. Psychiatrists working in correctional facilities should be informed about gender identity disorder in order to be part of an effective clinical treatment team.

—Annette Hanson, M.D.

DR. HANSON is a forensic psychiatrist and co-author of Shrink Rap: Three Psychiatrists Explain Their Work. The opinions expressed are those of the author only, and do not represent those of any of Dr. Hanson’s employers or consultees, including the Maryland Department of Health and Mental Hygiene or the Maryland Division of Correction.

1. Fields v. Smith, 712 F.Supp. 2d 830 (2010)

In 1920, a former stable worker and handyman by the name of Harry Crawford was arrested in Australia for the murder of his wife. There was no apparent motive for the murder until Crawford’s daughter revealed that her “father” was actually Italian-born Eugenia Falleni, a woman who had concealed her biological gender throughout the marriage.

The murder was precipitated when the victim discovered Crawford’s deception and threatened to reveal it. The trial and sexual ambiguity of the defendant captivated the early 20th century media and is the first well-documented case of a gender-disordered prisoner. Falleni served 11 years in a women’s prison, living her opposite-gender role.

The Diagnostic and Statistical Manual IV-TR defines gender identity disorder as a strong persistent identification that one is actually the opposite gender. The identification has to be strong enough to cause discomfort with one’s own gender identity and distress or impairment in social and occupational functioning. The prevalence of gender identity disorder in the United States is unknown. The California prison system has estimated that it contains hundreds of transgendered prisoners.

The treatment for gender identity disorder is outlined in the World Professional Association for Transgender Health (WPATH) guidelines. The WPATH guidelines describe three stages of treatment: psychotherapy, two years of living in the cross-gendered role with hormone therapy, and finally sex reassignment surgery. Most treatment for gender identity disorder is not reimbursed by insurance companies.

The correctional environment contains several barriers to compliance with WPATH guidelines. Initially there was controversy about whether gender identity disorder was a medical or a mental health condition, leading to conflicts within the facility regarding which department bore responsibility for treatment.

Many correctional clinicians lacked experience evaluating sexual disorders and had difficulty distinguishing between gender identity disorder and homosexuality. Finally, physicians unfamiliar with hormonal therapy lacked the experience to prescribe and monitor the medication.

Because of these barriers, jails and prisons originally did not offer treatment for the condition. Inmates coming in to a facility on hormonal therapy had their medication discontinued, leading to episodes of depression and self-injury or even genital mutilation.

In the 1990s, individual lawsuits filed by transgendered prisoners led courts to recognize gender identity disorder as a serious medical condition for which treatment was constitutionally mandated. Jails and prisons were required to continue hormone therapy for inmates being treated prior to incarceration, and to provide psychotherapy for the condition and its associated problems. By 2007, 18 states had policies related to transgender inmate health care.

Currently, transgendered inmates are generally recognized as having a right to mental health counseling and hormonal therapy.

In 2003 the Canadian Federal court ruled that transgendered prisoners could not be categorically denied sex reassignment surgery. Across the border, Wisconsin promptly passed Act 105, also known as the “Inmate Sex Change Prevention Act,” which barred the use of prison health care funds for hormone therapy or sex reassignment surgery. The Federal district court ruled the law unconstitutional in the 2010 case Fields v. Smith.(1) The court pointed out that the law blocked physicians from using their professional discretion for treatment decisions. The court also ruled that cost could not be used as an excuse to deny treatment, since the annual cost of hormone therapy was substantially less than the cost of organ transplantation and open heart surgical procedures, which the Wisconsin prison system did provide. Also, hormone therapy costs only $1,000 per inmate per year, less than half the cost of atypical antipsychotic therapy.

Two months ago the U.S. Supreme Court declined review of the case, meaning that now sex reassignment surgery may be provided to prisoners on a case-by-case basis. Presently, individual prison lawsuits for sex reassignment surgery are being pursued in Massachusetts and California.

The National Commission for Correctional Health Care, the agency that accredits jails and prisons, has a position statement regarding the treatment of transgendered prisoners which recommends medical treatment in accordance with WPATH standards, or surgical treatment if indicated on a case-by-case basis.

The correctional management of transgendered inmates is an evolving issue. In addition to changes in policy regarding medical care, some systems working in conjunction with advocacy groups have developed specialized housing units or tiers specifically for these prisoners. Psychiatrists working in correctional facilities should be informed about gender identity disorder in order to be part of an effective clinical treatment team.

—Annette Hanson, M.D.

DR. HANSON is a forensic psychiatrist and co-author of Shrink Rap: Three Psychiatrists Explain Their Work. The opinions expressed are those of the author only, and do not represent those of any of Dr. Hanson’s employers or consultees, including the Maryland Department of Health and Mental Hygiene or the Maryland Division of Correction.

1. Fields v. Smith, 712 F.Supp. 2d 830 (2010)