Managed care

[Sirimboi]

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I have mixed feelings about this subject. I understand theyare supposed to reduce spending of Medicaid. So they are policing the spendingand abuse of insurance, but from who? From patients who are abusing the system?From doctors who run unnecessary tests or keep patients in hospital unnecessaryto bulk up their billing? If that's true, they are failing miserably.

2 patients last week, 2 sides of the story (let's say hypothetical,for sake of confidentiality).

One is a frequent flier. Came in "suicidal" and ERadmitted him in spite of our D/C summary saying he is malingering and would notbenefit from further admissions. Patient said he is going to jump in front ofcar outside ER if not admitted, so the attending folded and admitted. We runPSYCHE for him and I was astonished. Since Jan 1st of this year he spent 195days in various inpatient units around the city. Last year, 2011, he spent 280days in hospitals. 2010 - 270 days. Often times he literally walks to a secondhospital hours after being discharged. I don't even want to know how much thisguys is costing tax payers. He has straight medicaid. Where is managed carewhen you need them?

Second patient: young woman, first psychotic break. 5 daysafter admission, continues to hear voices running derogatory comments abouther, not commanding in nature. They are barely audible and she can ignore them,but she continues to be scared by the whole experience. Her managed careMedicaid insurance asks for MD to MD evaluation and a really bored doctor,barely intelligible on the phone, tells me that because the voices are notcommanding in nature she is no longer in immediate danger to herself/others andthey are going to stop payments. She tells me that we can appeal and hang up. Ikept the patient 2 more days (administration was pretty nice about it), butstill had a heavy heart when she was discharged.

Is there really a solution to this?

 

[toothless rufus]

I have mixed feelings about this subject. I understand theyare supposed to reduce spending of Medicaid. So they are policing the spendingand abuse of insurance, but from who? From patients who are abusing the system?From doctors who run unnecessary tests or keep patients in hospital unnecessaryto bulk up their billing? If that's true, they are failing miserably.

2 patients last week, 2 sides of the story (let's say hypothetical,for sake of confidentiality).

One is a frequent flier. Came in "suicidal" and ERadmitted him in spite of our D/C summary saying he is malingering and would notbenefit from further admissions. Patient said he is going to jump in front ofcar outside ER if not admitted, so the attending folded and admitted. We runPSYCHE for him and I was astonished. Since Jan 1st of this year he spent 195days in various inpatient units around the city. Last year, 2011, he spent 280days in hospitals. 2010 - 270 days. Often times he literally walks to a secondhospital hours after being discharged. I don't even want to know how much thisguys is costing tax payers. He has straight medicaid. Where is managed carewhen you need them?

Second patient: young woman, first psychotic break. 5 daysafter admission, continues to hear voices running derogatory comments abouther, not commanding in nature. They are barely audible and she can ignore them,but she continues to be scared by the whole experience. Her managed careMedicaid insurance asks for MD to MD evaluation and a really bored doctor,barely intelligible on the phone, tells me that because the voices are notcommanding in nature she is no longer in immediate danger to herself/others andthey are going to stop payments. She tells me that we can appeal and hang up. Ikept the patient 2 more days (administration was pretty nice about it), butstill had a heavy heart when she was discharged.

Is there really a solution to this?

What is runPSYCHE?

 

[member2721]

Anyone have thoughts about ACOs (accountable care organizations)?

Sounds like it may help realign some of the incentives to emphasize providing quality rather than quantity.

 

[F0nzie]

Solution: Increase mental health funding and bolster diversion programs. When you have a patient that states they are suicidal with plan and intent and you refuse to admit them, it's your word against theirs. If you're stuck between admitting and letting them go on the streets, being cautious and admitting may be safer for both parties. On the other hand, if you had strong diversion programs for chronic issues you could divert to subacute, step-down, level 2, or a 24 crisis facility to mitigate some of the costs associated with level 1 inpatient. In cases where I do not have the option to divert, and I am convinced the pt does not need to be hospitalized, I have social work call their mental health agency and formulate a plan ie. wellness check, phone call, early appointment, and enlist additional family support. However, I would really need to see that the patient can engage in a therapeutic alliance and follow through with these recommendations before I decide they can go home. Patients should be placed in the least restrictive environment for their condition, however, if there is no funding for alternatives your hands are tied. The bottom line is unless we increase funding to mental health, hospitals and taxpayers will be footing the bill for overflowing emergency rooms and inpatient medical beds.

 

[vistaril]

Solution: Increase mental health funding and bolster diversion programs. When you have a patient that states they are suicidal with plan and intent and you refuse to admit them, it's your word against theirs. If you're stuck between admitting and letting them go on the streets, being cautious and admitting may be safer for both parties. On the other hand, if you had strong diversion programs for chronic issues you could divert to subacute, step-down, level 2, or a 24 crisis facility to mitigate some of the costs associated with level 1 inpatient. In cases where I do not have the option to divert, and I am convinced the pt does not need to be hospitalized, I have social work call their mental health agency and formulate a plan ie. wellness check, phone call, early appointment, and enlist additional family support. However, I would really need to see that the patient can engage in a therapeutic alliance and follow through with these recommendations before I decide they can go home. Patients should be placed in the least restrictive environment for their condition, however, if there is no funding for alternatives your hands are tied. The bottom line is unless we increase funding to mental health, hospitals and taxpayers will be footing the bill for overflowing emergency rooms and inpatient medical beds.

the problem is, as the OP mentions, this patients who are CLEAR MALINGERERS sometimes get admitted depending who is on. These patients don't need 'diversion programs' or a PHP or a followup appt(that they will never go to)....they need to be removed from the ER, with police assistance if need be.