Pouring A Little Payee Sauce On It

[clement]

So you're in the ED and it's a whack fest with your pager blowing up. Say you have a suspected potential malingerer on your hands. You note that he or she has been hospitalized a couple times in the past. How unethical is it to mention the potential prospect of a payee, if admitted? I know people who do this, but I don't know...Is it...Bad?

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[myPsychAlt]

hospitalized "just a couple times" is low for my ED.

 

[billypilgrim37]

Misread original post. Apologies.

What is your goal in doing this?

First, you may be wrong. If you are, you tell the insurer this guy might be malingering, you just robbed him of treatment. Hippocrates rides up and beats you to death with a caduceus.

If you are hoping you can go tell the guy "we can't admit you, the insurance company won't approve it," well, I hope you have tremendously good malpractice insurance. Whether the insurance company pays or not has nothing to do with your liability. They can reject, but if you are the guy that just sent the dude who commits suicide out the front door of your ED, then the plaintiff lawyers are going to crush you. And rightly so.

If you are doing it just wanting to punish him, then you're a sociopath rather than a physician. You probably AREN'T a sociopath, which is why you shouldn't do this!

Lastly, we already have enough problems with folks on the phone from the insurance companies trying to dictate the care we give the patients we see in front of us. In some situations this is reasonable, but in the psychiatric ED, as a physician, you want to be in as much control of the situation yourself as you can be. You don't want Marsha the psychology BA who is angry because she is having to take your call at 3 in the morning making decisions for you about the patient sitting across from you in the exam room.

I can understand the poetic justice that a resident in a busy psych ED could fantasize about, but that's all it is, a fantasy. Otherwise, someone could easily accuse you of negligence, and they might not even be wrong.

 

[mahasanti]

What is your goal in doing this?

First, you may be wrong. If you are, you tell the insurer this guy might be malingering, you just robbed him of treatment. Hippocrates rides up and beats you to death with a caduceus.

If you are hoping you can go tell the guy "we can't admit you, the insurance company won't approve it," well, I hope you have tremendously good malpractice insurance. Whether the insurance company pays or not has nothing to do with your liability. They can reject, but if you are the guy that just sent the dude who commits suicide out the front door of your ED, then the plaintiff lawyers are going to crush you. And rightly so.

If you are doing it just wanting to punish him, then you're a sociopath rather than a physician. You probably AREN'T a sociopath, which is why you shouldn't do this!

Lastly, we already have enough problems with folks on the phone from the insurance companies trying to dictate the care we give the patients we see in front of us. In some situations this is reasonable, but in the psychiatric ED, as a physician, you want to be in as much control of the situation yourself as you can be. You don't want Marsha the psychology BA who is angry because she is having to take your call at 3 in the morning making decisions for you about the patient sitting across from you in the exam room.

I can understand the poetic justice that a resident in a busy psych ED could fantasize about, but that's all it is, a fantasy. Otherwise, someone could easily accuse you of negligence, and they might not even be wrong.

?????
What does this have to do with the prospect of a payee?

Personally, I think that if you highly suspect the misusing of funds, then explaining the likelihood of a payee is only fair.

 

[Sneezing]

If that's what you think is appropriate, put it down. Write is as "Consider investigating utility of payee when on inpatient unit." It'll be up to that service down stream to determine if it is appropriate or not. Physicians ignore other physicians recommendations all the time. Ever been on a consult service?

 

[billypilgrim37]

?????
What does this have to do with the prospect of a payee?

Personally, I think that if you highly suspect the misusing of funds, then explaining the likelihood of a payee is only fair.

All apologies, I misread the original post. I thought this was a matter of telling the INSURANCE COMPANY you thought the patient was malingering.

 

[clement]

No no....So to uncover someone you think might be malingering, you mention the prospect of a payee (someone who will control their finances) if again admitted...For some, this will cause them to retract SI or HI...But, I'm not certain this is full-proof. No one wants another person to control their finances. So I was wondering, unethical?

 

[watto]

In a similar vein, how about "you can't smoke on the inpatient unit," if that is indeed the case?

 

[splik]

what is the specificity and sensitivity of mentioning of a payee in the unconvering of malingering? not very high for either i would suspect, and thus yes it is unethical. there is usually some element of doubt and most malingerers have some level of psychopathology (and very commonly a severe mental illness and not simply Axis II pathology) which is what make these patients tricky as well. If it were as simple as this patient is obviously malingering, they wouldn't be admitted. I know its a bit more complicated than that, but the possibility must remain or be claimed that the patient is truly a danger or whatever otherwise you wouldn't simply hospitalize. And of course even malingers get sick. In fact, they get sick a lot more often, which is how they learnt the benefits of malingering in the first place.

 

[nitemagi]

what is the specificity and sensitivity of mentioning of a payee in the unconvering of malingering? not very high for either i would suspect, and thus yes it is unethical. there is usually some element of doubt and most malingerers have some level of psychopathology (and very commonly a severe mental illness and not simply Axis II pathology) which is what make these patients tricky as well. If it were as simple as this patient is obviously malingering, they wouldn't be admitted. I know its a bit more complicated than that, but the possibility must remain or be claimed that the patient is truly a danger or whatever otherwise you wouldn't simply hospitalize. And of course even malingers get sick. In fact, they get sick a lot more often, which is how they learnt the benefits of malingering in the first place.

If you suspect someone is trying to game the system, recognize that any single intervention to discourage is really a process of an arms escalation (and mutually assured destruction in many cases). If you escalate, they may find a loophole, or raise the stakes. I've unfortunately seen this play out even in retaliatory or vengeful suicide attempts. Just something to keep in mind.

A fair point brought up, though, of if you're not sure they're malingering, be careful to not label them as such. You can grade your level of suspicion, but it would be bad to label them as such and be wrong.

 

[Salpingo]

So you're in the ED and it's a whack fest with your pager blowing up. Say you have a suspected potential malingerer on your hands. You note that he or she has been hospitalized a couple times in the past. How unethical is it to mention the potential prospect of a payee, if admitted? I know people who do this, but I don't know...Is it...Bad?

I'm still kind of confused how a payee applies to this situation. From my understanding, its a service provided by a housing/community health service to dispense government funds for basic needs. Would you require it for admission? Are you assuming the patient is receiving government funding?

 

[nitemagi]

I'm still kind of confused how a payee applies to this situation. From my understanding, its a service provided by a housing/community health service to dispense government funds for basic needs. Would you require it for admission? Are you assuming the patient is receiving government funding?

It's attempting to threaten the patient, basically. "If you insist on forcing my hand to admit you, I'll have to apply to get you a payee."

 

[clement]

I don't dispute the view that malingerers suffer at least some degree of psychopathology. Can this be in any meaningful way modified in the context of acute inpatient hospitalization? And just to play Devil's advocate, how about the ethics of such an individual taking up a bed in place of someone who is truly suicidal or homicidal? Nothing is more demoralizing than admitting the guy who wants a break from his wife and kids and spends the whole admission making fun of truly ill patients. This guy then even gets a disability letter out of the whole thing. Ive seen it happen and it's flawed. It stems from liability fears to some extent and it's more prevalent in some hospital systems compared to others.

 

[peppy]

nothing is more demoralizing than admitting the guy who wants a break from his wife and kids and spends the whole admission making fun of truly ill patients. This guy then even gets a disability letter out of the whole thing. Ive seen it happen and it's flawed. It stems from liability fears to some extent and it's more prevalent in some hospital systems compared to others.

Yes, I do agree that these kinds of admissions are a bigger problem at some hospitals than others. It's absurd that at some places anyone who mentions the idea of suicide gets admitted, just as it would be crazy if ER doctors automatically admitted everyone who complains of chest pain. We should have the medical judgement to be able to assess the risks and weigh if a patient really does need to be in the hospital or not.

 

[whopper]

This is a problem that hasn't been addressed in a conventional sense IMHO because everyone's too chicken to deal with it. Professional organizations such as the APA, for example, aren't making directives on how to deal with this issue in a clear manner. The problem here is in a clinical setting, you can't bill for a malingerer investigation to the degree that does it justice.

In a forensic setting, you have leeway because the Court wants you to investigate these things, and when you've figured out someone's been malingering, with several days of documentation and psychological testing backing it up, you're on solid ground. I've had cases where the patient was literally hospitalized over a dozen times, with each hospitalization IMHO being bull, and I took them off their meds for several weeks and figured out they were malingering and declaring it in Court.

If you were to play hardball with someone you suspect is malingering with little documentation, only a one-time evaluation, and no psychological testing, you're on shaky territory. In emergency psychiatry, you don't have the time to figure these things out because you're supposed to just get the patient to the next level ASAP unless it's very apparent or you've seen the person several times. In inpatient, if you suspect malingering, even find it happening, you usually can't bill for it, but you got a person who's been in the hospital for a few days, and by then teh administration might put pressure on you to diagnose the person with whatever NOS (or as someone I knew called it FOS) so the institution won't be in the red.

Another problem I've noticed is clinical psychiatrists without forensic training often times don't know how to deal with this. Just as an example, during my forensic fellowship, one of my clinical instructors was a non-forensic psychiatrist who oversaw my work. I was convinced with strong evidence that someone receiving a government check monthly for mental illness was not mentally ill. The evidence was solid. He still didn't want me to make a move to get the payments cut.

A payee IMHO is not a bad option all things being equal. I wouldn't recommend it in all cases but if you suspect malingering, it does at least add some extra obstacles to someone who may be misusing the funds.

 

[loveoforganic]

Question of ignorance - what is a payee?

 

[nitemagi]

Question of ignorance - what is a payee?

Someone appointed to handle another person's finances. There are different names in different states, such as a fiduciary, or a guardian.

 

[loveoforganic]

gotcha, thanks

 

[atsai3]

With regards to watto's question, when it comes to a patient for whom you are recommending acute inpatient care, you should be upfront about what that involves. Many people envision a spa weekend and don't envision loss of smoking privileges, waking up at 8:00am to attend groups, etc.

 

[whopper]

Some things I used to do that I felt were not crossing into the unethical were...

No benzos--ever for suspected malingerers. Not even PRN. You give them PRN, half the time a nurse that just wants an easier day gives it to the patient to shut them up.

No Seroquel. It's got a street value; besides is a piss poor antipsychotic compared to other antipsychotics per CATIE: lots of side effects, little efficacy.

No sandwich to shut them up in the emergency center. While it's a common practice to offer food in an attempt to ease frustration, if you have strong reason to believe the person's malingering don't give them an easy time.

Low-salt, cardiac diets, even if they are healthy. Hey it's healthy anyway.

If you have the power to do so, no activities that a typical malingerer would want. This is usually only an option in a long-term facility where there are hundreds of patients and a choice of several groups. E.g. no groups where they can use the Internet, no groups where they can hook up with patients of their sexual preference, no fun groups such as basketball, (unless you're trying to figure out their malingering. Give a malingerer something fun like a basketball, he might go from disorganized thought process to all of a sudden playing very well.)

Patient has to wake up to attend morning meetings. If not, well as my attending used to say to people he suspected were malingering, "You came here because you wanted treatment, and now you aren't using it. If that's the way you want it you shouldn't be here."

Now all this said, you must be very very careful because to treat a patient who is truly mentally ill and in need of treatment in a disrespectful manner could likely make their illness worse.

If malingerers really frustrate you, this to me is a good reason to consider forensic psychiatry. You'll get training on how to deal with malingerers for real in some programs (not so much in others).

 

[Apollyon]

Low-salt, cardiac diets, even if they are healthy. Hey it's healthy anyway.

Other fine dietary choices: diabetic, low potassium, and the king - low phosphorus. The low phosphorus diet is like cardboard. Combinations, like the cardiac diabetic diet, are also surreptitiously nearly inedible.

 

[psychphan]

Personally I don't see how bringing up the idea if a payee is any less ethical than a number of things I've seen or others have suggested (withholding unit privledges, prescribing 'nearly inedible' diets). Now actually applying for a payee for someone you believe is malingering, I think that's unethical. But mentioning it to a pt doesn't seem unreasonable.

 

[Apollyon]

Personally I don't see how bringing up the idea if a payee is any less ethical than a number of things I've seen or others have suggested (withholding unit privledges, prescribing 'nearly inedible' diets). Now actually applying for a payee for someone you believe is malingering, I think that's unethical. But mentioning it to a pt doesn't seem unreasonable.

If you think that withholding unit privileges or prescribing an unpalatable diet is unethical, or is skirting that point, then maybe you should revisit any ethics training or education that you have had in medical school. You seem unclear on the subject; just because you object does NOT make it unethical.

And, as far as the diet - I went to the next step, but whopper was right - the cardiac diet IS healthy.

 

[psychphan]

If you think that withholding unit privileges or prescribing an unpalatable diet is unethical, or is skirting that point, then maybe you should revisit any ethics training or education that you have had in medical school. You seem unclear on the subject; just because you object does NOT make it unethical.

And, as far as the diet - I went to the next step, but whopper was right - the cardiac diet IS healthy.

You misunderstood. I certainly don't think those things are unethical. Likewise, I don't think it's unethical to mention the IDEA of a payee to a patient.

 

[whopper]

If you think that withholding unit privileges or prescribing an unpalatable diet is unethical,

My personal opinion-it is unethical unless there's strong reason. I personally wouldn't do the low K diet thing unless I had strong evidence (not saying it's a bad idea in those cases). I've seen several health providers believe their training allows them for more than what's allowed. Believing someone is malingering simply based on a whim or circumstantial evidence such as a prior history of drug abuse is IMHO is overstepping it.

From personal experience I've seen more attendings err on the side of caution a bit too much and be very exploited by malingerers, but I've also seen doctors a little too eager to press the malingering trigger.

The best option with malingerers is to try to figure out why they are doing it, and then see if you can somehow help in that area that's within therapeutic guidelines. I had one homeless lady, for example, in the ER, and I could tell she was malingering. I told her a hospital stay costs the system several thousands of dollars and that this type of monetary use needed to be better spent on people who really needed it. She told me she was exaggerating her symptoms and didn't know how expensive it was and cooperatively told me she was just going to go back to the homeless shelter.

The above type of case is the exception, not the norm, but it's better to see if there's someway the malingering can be dealt with cooperatively with the patient.

Another option I didn't mention is if you suspect malingering, look up the patient's court-records. About 10-20% of the time I've seen a malingerer, even in a non-forensic setting, they're wanted by the law and it turned out was merely trying to stay in the hospital as a method to hide out from the cops. In Ohio, we have access to court-records in the hospital computer.

In residency, whenever we had a malingerer wanted by the law, we'd tap our wrists twice (kinda like as if they were in handcuffs) as a type of signal to the rest of the team to inform them what was going on with that patient.

 

[Apollyon]

To be collegial and honest, on reflection, my memories and experiences are based on my time in IM. From my having to do "ghetto psych" in the ED, I do not begrudge you folks your difficult and nuanced job. As an aside, in the ED, there is little choice of the food - so, if it is good (like the vaunted "Duke turkey sammich"), folks want it. If not, well, that's what ya get!