More on Private Practice

Yesterday, I worked from 8:30 AM to 8:30 PM and basically crammed everything I could into the hours. I ate lunch in 10 minutes at my desk. And I still didn't get caught up. It's true that I'm learning a new electronic medical record that is quite complex and takes a lot of time to customize to my particular documentation. But I'm also having to learn an even more complex and arcane set of rules for documenting my activities for the purposes of billing. The currency of the medical realm is called a Weighted Relative Value Unit or RVU. Each procedure or visit is worth a certain number of RVUs. RVUs supposedly take into account the length of training and expertise, risk and so forth and were originally developed as a way to rationalize a payment system that had simply developed naturally over time. One of the key criticisms of the RVU system is that it rewards procedural specialties like surgical subspecialties, radiology or interventional cardiology. So-called cognitive specialties such as general internal medicine, pediatrics or psychiatry are reimbursed at a much lower rate. As a colleague of my once said, "The closer you are to the patient the less you get paid," and unfortunately it's true. This is why medical students are choosing procedural specialties over primary care and psychiatry.

At any rate, although I don't even know yet how much cash an RVU is worth, I have a two-page printout with the RVU value for each of about 40 different procedures that I might use. That is, I know the relative value of one thing over another. This is already driving my behavior, since I want to maximize my income. So now I carry around my RVU chart and am trying to memorize it. Note that a specific activity might be billed in one of several ways, so I'm going to choose the procedure code that nets the highest price. Each procedure has a complex formula involving a point system for various aspects of taking a history, examining the patient, interpreting labs and xrays, and the complexity of medical decision-making. So I'm learning to include certain things in my notes that have little import because the bureaucracy requires it. The hospital has many different coders who pore over notes and make sure that the documentation has the requisite elements to justify the procedure code. Each insurance company including government agencies have huge staffs who do nothing but make sure that documentation supports the procedure. Keep in mind that there is no reason to believe that any of this adds to patient care or improves outcome. In fact, it is not only a distraction and decreases actual patient care time, but it adds enormously to the cost of health care, all the while creating no added value.

When I was working directly for the patient, that is, through self-pay, I charged an hourly rate no matter what kind of activity I was engaged in, and as long as the patient was satisfied with the service. When patients called me, they called my cell phone, not a nurse or receptionist. I could treat more patients because I could do telephone care and secure messaging and texting and get paid for it. Now, I have to schedule a visit because nothing else gets paid for. This decreases my true productivity and inconveniences the patient unnecessarily, and also costs more because the patients often have to take off work to see me.

This system is one that rivals Alice in Wonderland. What it will take to change it is unclear to me. But I have to say I prefer both the salaried approach used by the VA and the self-pay system to this wierd, complex, arcane and burdensome system. No wonder the US spends 30 cents of every health care dollar on administration and meanwhile gets care that often falls short of even minimal expectations.

Private Practice is no Picnic

Since my return to Minnesota, I've been working  in a private practice health care organization in a highly managed care environment. I've worked previously in the Veteran's Health Organization (VA) and in a self-pay environment in Washington, DC, but not in this type of organization. It's been fun, invigorating, and challenging. And, it's giving me insight into some of the challenges facing American health care today.

One of the biggest concerns is that reinforcers of behavior are misdirected, guaranteed to induce behavior on the part of clinicians that result in net harm to patients. Here's an example: I tend to spend more time with patients and families, and I am penalized for that. There are other psychiatrists in the community that see patients for 5 mins or less for a medication check. I'm sorry, but I don't understand what can be really assessed in 5 mins. However, if I continue this way, she makes more money than I do. What message does this send? Do we expect doctors to be saints? I can tell you that idealism and professionalism go only so far. A new furnace, private school for the kids, and an occasional vacation for my wife and I are powerful competitors with idealism. 

What do we really want to reward in health care? How much would it take to meet everyone's needs, and if we can't do that how do we decide who gets what?

How do I resolve between my ideals (I've served poor people most of my career) and my personal needs (I have various debts to pay off, the house needs maintenance and we need a new car)?

At the same time, I feel that I am providing a service that people have not experienced before: true professional addiction medicine/psychiatry. Someone who can manage the complex patients, rather than just evaluating them for rehab. I've been surprised by the range and complexity of the patients I've encountered so far. My experience only increases my motivation to change the way we do business. We need to be providing truly professional science-based recommendations and treatment. And by and large, consumers do not have access to that. Rehab services are extremely imporant for those who cannot stabilize at home. In Minnesota, there are more programs than usual who are focused on providing evidence-based treatments such as Suboxone therapy for opioid dependence and pharmacotherapy for alcohol dependence. But what's difficult to access is professional treatment by physicians, the way diabetes, asthma, cancer, hypertension, and depression are treated. My goal is to create a system that will do just that.

Back in Minnesota: Opportunities and Barriers to Change

Blog entry 1-20-10

Well, it’s been over a month since I entered something in my blog. (I’m sure the millions of faithful readers have been wondering what happened.) Well, two things. The holidays. And re-entry. I’ve been negotiating re-entry into my family, my home in Minnesota, into the professional community of St. Paul-Minneapolis, and into a local health care organization (HCO) called Allina. Paul Goering, a psychiatrist and director of mental health services for Allina (a collection of hospitals and clinics in the metro area) was kind enough to not only give me a job on my return to the Twin Cities, but he also has recognized an opportunity to change the way we treat addiction. He has said repeatedly that “the way we treat addiction is not satisfactory” but that up to now there haven’t been any alternatives. Paul, besides being a really nice human being, is a skillful administrator who has made my return here much easier than it otherwise might have been. In addition, someone else I met this fall, Bobbi Cordano, is a human dynamo who serendipitously became the interim director for something called the Center for Clinical Innovation at Allina. The Center is still finding its way, but it’s devoted to supporting innovation in the delivery of services, particularly as they affect the broader community. She and I have also been talking about ALATYR, my initiative to change the way we treat addiction in America, and how we might work together to make it happen.

I have encountered other opportunities as well. The state of Minnesota Department of Human Services is interested in looking at ways to improve addiction treatment and I am in discussions with them about how to make it happen. Upon returning to Minnesota, I have been very impressed with how progressive the medical community is here, and how much the various health care organizations seem to be focused on improving care more than on making money (although they of course have to do that.) The fact that HCO’s in Minnesota have to be non-profit by state law may have something to do with this, but Minnesota also has a tradition of progressive politics and a communitarian focus. All in all, it appears there are many potential opportunities here to try out my ideas about a public health approach to substance use.

It’s also been interesting to practice in a private HCO in a highly managed care environment. Minnesota, Massachusetts, California and Seattle have led the nation in early penetration of managed care and at least in Minnesota virtually all health care is managed. (In contrast, in Washington, DC, it seems that very little of it is.) I had a small self-pay private practice in Washington before moving back here, but this is very different. And it’s giving me insight into some of the problems with our current system.

For one thing, the incentives are all wrong. I can only get paid for face-to-face time with patients, even though it would be more efficient and effective to work with a team of professionals such as nurses and therapists who provided various parts of care. Reimbursement for psychiatrists is greater for medication management alone rather than combined treatment with psychotherapy and medication management, which in my experience is more effective and is strongly preferred by many patients. A great deal of time (and money) is spent by multiple people to meet bureaucratic requirements of insurance companies and Medicare, while providing no benefit to patients whatsoever. There is no incentive to provide better outcomes, and in fact no measurement of outcomes. There is no incentive to provide better care or care based upon current evidence. Patients and families are left to their own devices to figure out where to get care, and who might be better at particular types of care, other than the annual “Best Doctors” issues of local magazines. In short, the current system with all its many interlocking components makes it extremely difficult to do the right thing. In my experience, it’s the system that determines the quality of care, not the individual provider. If we can’t line up the incentives more rationally, we are doomed. I must add, parenthetically, that the individual professionals at all levels seem to be devoted, careful clinicians and support staff who truly believe in what they do and want to provide the best care they can. The problem isn’t the people in the system- the problem is the system.

In the next few postings, I’ll share further experiences and insights as I care for patients and interact with the HCOs and government.

Military Service Members, Veterans and Their Families

This past week, I spoke at the 2^nd Annual Trauma Spectrum Disorders Conference, which is a scientific conference on the impact of military service on families and caregivers, held on the National Institutes of Health campus in Bethesda, MD. Many government agencies collaborated, including NIH, the Department of Defense, the Veterans Administration, the Department of Health and Human Services and others. I applaud these agencies in their efforts on behalf of those who have borne the burden of our recent military campaigns in Iraq and Afghanistan. The focus of the conference was on translation of research findings into clinical care and policies and identification of priority areas needing additional research. This conference offers a good example of the challenges of evidence-based medicine (EBM).

The fact is that using research findings to guide care is seldom straightforward. Most areas of medical care do not have high level research evidence underlying them. Even where high-level evidence is present, applying it is not easy. Most high-quality studies are highly controlled efficacy trials in academic health centers. In order to isolate the question being investigated, study participants are carefully selected. People with other serious medical, psychiatric or substance use disorders are often excluded, as are people with no transportation or who have to work two shifts a day to make ends meet. Studies are usually time-limited, although most diseases are chronic. The level of care provided in efficacy trials is almost always higher than that in usual care. Thus, generalizing findings from efficacy trials to community care is difficult, because patients in the community differ in systematic ways from study participants and community care necessarily lacks the rigor present in efficacy trials. For example, in an excellent NIH-funded study comparing different treatments for attention deficit disorder (ADD), stimulant medication was found to be a highly effective when rigorous medication management procedures were employed, but was not at all effective as used in common practice where systematic follow-up and careful medication treatment protocols were absent.

A related problem is that clinical research is very expensive and time-consuming. Thus, clinical realities often race ahead of the research. Neither clinicians nor consumers feel they can wait for the next study before acting. This is certainly the case for military service members and their families. Many medical advances, especially in trauma care and surgery, are made on the battlefield out of desperate necessity. Exposure to battlefield conditions may lead to previously unknown disorders, such as Gulf War Syndrome, that nevertheless require treatment (and determinations regarding disability.) It has taken a long time to address Post Traumatic Stress Disorder (PTSD), Traumatic Brain Injury (TBI) and the disorders that often accompany them such as substance use and other psychiatric disorders. Management of chronic pain remains controversial and difficult. Spouses, children and extended family members of those who are serving also experience serious stress including financial strain, prolonged absence of their loved one and having to care for a veteran with service-related injuries including PTSD and TBI. In none of these areas is there a strong evidence base providing guidance. Yet, we have a responsibility to do what we can. That’s what I spoke about today, and I’ll discuss that more in a future post.

What's Needed to Transform the Treatment System?

Today I heard a presentation by Tom McLellan, PhD, the Deputy Director of ONDCP, outlining the priorities of the Obama administration concerning “demand reduction,” i.e. prevention and treatment. Dr. McLellan and those he works with are to be commended for developing a thoughtful and comprehensive approach. You can read more about it here: http://www.whitehousedrugpolicy.gov/policy/demand_iwg.html

At the same time, I have some concerns about their approach. My overarching concern is that it may not fundamentally alter the care system in the country but instead attempt to incrementally improve the existing one. I think the existing one, based on a now outmoded idea, is so flawed that it cannot be sufficiently improved. Instead, we need to move in a more transformative way, offering a completely new way of thinking about and treating substance use disorders.

One particular concern is that their approach seems unlikely to close the largest treatment gap there is: the people lying between at-risk users (the target of SBIRT) and people with severe, chronic or recurring dependence (the target of traditional treatment programs.) Between lie all the people with mild to moderate dependence who remain highly functional even though they are concerned and are struggling with their use. They primarily have symptoms of compulsive use: using larger amounts and for longer times, persistent desire to quit/down and being unable to do so, and using despite psychological or physical symptoms caused/exacerbated by use, such as hangover or insomnia. Serious functional impairment only occurs in a relatively small minority of users. For this group, addiction is seldom a chronic disease. This is demonstrably so for alcohol dependence. I suspect the same is true for other substances (especially cannabis) but the proportions may vary (there may be fewer functional cocaine, meth or opioid users relative to functionally impaired addicts.) These functional dependent persons are the people who “do not perceive a need for treatment.” I strongly believe, however, that there is an interaction between perceived need for treatment and what that treatment is or is perceived to be. Don’t you think if treatment for alcohol dependence meant going to your primary care doctor or psychiatrist and receiving a medication and brief behavioral support that it would change perceptions about “need” for treatment?

The only way I can see to offer this group attractive, accessible, affordable care is through existing healthcare and mental healthcare systems. In ONDCP’s approach, treatment still seemed to be something that occurs in special places and that is done by special people (i.e., in rehab or opioid treatment programs.)

Finally, we need a robust medical addiction specialty sector to make any of this happen, and we need to define and disseminate a model of medical/psychiatric treatment for addiction. (By “medical” I mean a biopsychosocial approach, not just medication.) For example, most treatment for depression is done by non-psychiatrists, but I think that few doctors would try to treat depression if they didn’t have a psychiatrist to refer the difficult cases. Similarly, I think it is essential that there be sufficient, well-trained addiction psychiatry and addiction medicine physicians available to provide the chronic care management for complex, chronic disorders.

Transforming Treatment for Addictions in America

On October 31, I left NIH and and returned to St. Paul-Minneapolis, MN to rejoin my family. I'd like to share what my next project is: Transforming Treatment for Addictions in America. Of course it sounds grandiose, and perhaps it is. (If so, I'm sure I'd be the last to recognize it.) However, I think that the time is right for transformative change in this field, and that given the right effort and some luck, it could actually happen very rapidly.

Here's why. First, nearly everyone agrees that the current system of care is not meeting anyone's needs very well. Many people have difficulty obtaining access to treatment. Treatment is often of low quality and effectiveness yet can be very expensive. Treatment centers are able to offer just about whatever they want, regardless of whether there is scientific research or expert consensus concerning effectiveness. For example, at licensed treatment programs around the country, you could get hypnosis, yoga, meditation, treatment with nutritional supplements (which the program sells), treatment based on brain scans, and equine therapy (riding horses). It is almost certain that the treatment recommendation will be whatever that program offers, and there seems to be no felt ethical obligation to educate consumers about alternative treatments that may have better efficacy. Programs may offer seven days of treatment or six months. Thus, consumers are often confused about how to decide about where to go and what treatment is effective.

Second, consumers do not have any meaningful choice in the type of treatment available (except for the flaky stuff.) With the exception of methadone and Suboxone maintenance, more than 90% of US treatment programs offer group counseling and referral to AA. Period. Consumers don't like our programs, thus the majority have to be coerced into treatment. I often ask people what it would take to make them walk into a rehab program tomorrow and the nearly universal answer is: I'd have to have no other choice. Unfortunately, too many providers have become complacent, not needing to provide good customer service because their clients have no choice but to comply. Most importantly, there is very little access to newer treatments that are based on solid scientific studies. Every time I have had a national media interview in the press, I have received calls and emails from patients and families: where can I find a doctor to prescribe these medications [for alcohol dependence] that you were talking about?

Third, there has been a revolution in understanding of substance use and addiction that has radically altered our view of the spectrum of substance use and associated problems. This new understanding has significant implications for configuring a system of care. We now have the knowledge and tools to offer risk reduction and individualized treatment for a much broader group of people than ever before. Most people who drink more than is medically advisable have relatively mild dependence and remain highly functional. They have a much better prognosis than the more severely affected people who enter rehab programs. They can respond to less intensive and more discreet treatment if it were made available, and the only way to do that is through the existing system of health care. In the future, most people who develop alcohol dependence will go to their primary care doctor or psychiatrist and receive medications and brief behavioral support. This is the way we treat depression now, and although it's not perfect it has made treatment more accessible, affordable and attractive. Those with severe, recurrent disorders require care that is set up to manage the addiction and the co-existing health conditions over years to decades, not weeks or months. Chronic care management by physicians, nurses, and other professionals is needed and makes more sense than expecting a few weeks of group counseling to induce permanent recovery. The prognosis is much better than most people think, but it often takes several years to finally achieve recovery.

I am in the process of forming an initiative to transform treatment for addictions in America in the next five years. It is called the ALATYR Initiative. In the coming weeks, I will be describing this in detail, and sharing our progress.

Welcome to MOS

Hello and welcome to Matters of Substance, a new blog to facilitate discussions about current issues related to alcohol and other substance use conditions. There is no specific agenda other than that posts relate to substance use. Let's have fun!