American Madness

American Madness by Alice Feller, MD

BOOK PREVIEW

My study of mental illness began with a tenth-grade term paper on schizophrenia. I was hoping that my father had this illness, that his paranoia and violence were due to an illness. If he had schizophrenia he could get treatment and become normal, like other dads. After my research, I realized he did not have schizophrenia, but I have kept a life-long interest in psychosis.

American Madness began with my return to public psychiatry, where many of my patients suffered from serious mental illness. After decades in private practice, these clinics were a rude awakening. I knew that EMRs had taken over much of medicine, but I had never experienced their power to intrude into patient care. I had never known what it was like to spend half my time on the computer, documenting service for the purpose of insurance billing, or what it meant to work in a system that discouraged collaboration on patient care. I learned that after deinstitutionalization, in large part due to the IMD Exclusion, jails and prisons now provide 90% of our inpatient psychiatric care.

During my residency and later, at the VA hospital where I took a physician fellowship in substance abuse, and still later, when I ran a chemical dependency clinic at Kaiser Oakland, we kept accurate medical records. What we wrote was dedicated to patient care rather than insurance billing. We wrote or dictated what was important, including a discussion of differential diagnosis if appropriate. Upcoding to maximize insurance payments was not the widespread practice it is today.

Today the EMR twists our reporting to fit the computerized form, so as to ensure the highest insurance reimbursements. One day, I had a patient with psychosis who was unable to come to the clinic, so I saw him at his board and care home. He sat against the far wall, looking up anxiously at the ceiling to his right, and I realized that he was hallucinating. Clearly our conversation was excruciating for him, so after 5 minutes I ended the interview.

Unfortunately, the duration and location of all patient visits was preprogrammed into the computer: 25 minutes, at the office. I struggled to change it, but nobody could tell me how. “Just do it the same,” they said. I knew the length of the visit was for the purpose of Medi-Cal billing. An accurate note might open myself up to charges of Medi-Cal fraud, so I wrote a vaguely worded entry about his mental status and left out the most important supporting evidence.

There are other barriers to adequate patient care. When I remarked to one of my bosses that nearly all our patients carried a diagnosis of schizophrenia, he said, “The case managers put that in at intake. Just go ahead and make your own diagnosis.” What we did not say, of course, was that this routine diagnosis of schizophrenia was for the benefit of insurance billing; that code would guarantee the highest payment from Medi-Cal.

I had one patient, a young man who abused many substances, including alcohol, methamphetamine, and marijuana. His diagnosis in the EMR, of course, was schizophrenia, but he did not seem to have schizophrenia when I spoke with him. He was personable, friendly, and had none of the flat affect or other telling signs of schizophrenia. He was clearly confused, but I thought that might be due to his chronic use of cannabis. He had been hospitalized for suicidal depression, but any of the drugs he used could have caused that. I did not think we could properly evaluate him until he was detoxed and solidly drug-free.

To go with his official diagnosis, he was being prescribed large doses of antipsychotics, and I wanted to change that. They had never helped him before, and I worried about tardive dyskinesia. What we needed to sort this out was to know how he looked after those drugs had cleared from his system.

Luckily, I thought, he had spent 6 months at Sierra Sunrise, a long-term locked facility often used as a step-down unit. His doctors there would have had a chance to see what he was like when he was drug-free. Did he seem to fit his incoming diagnosis? In the safety of that facility, they would have given him a trial off his antipsychotics, I assumed. I felt strongly that he would have shown no signs of psychosis.

I got a signed release from him and set out to reach Sierra Sunrise to answer the question of diagnosis. I called, sent the release and request for records, called again and then called again. I never once got a response. When I asked a colleague about getting records from Sierra, she said, “Oh, we don’t get those.” I was shocked, but she saw it as unremarkable.

More and more, insurance considerations dictate our decisions. In private practice, I became wary of taking on a patient if I would have to bill their insurance to get paid. It is not that the insurance pays less than my full fee; it is that often the insurance does not pay at all.

While I was working at the service center in Oakland, we received a memo from our Quality Assurance (QA) officer. It was a list of words or terms that had to be spelled out in our EMR note or the claim would be denied. This would add even more time to our documentation duties. The list was 10 pages long, single-spaced. Many of the terms were common in everyday language, such as “24/7.” Many more were medical terms that should have been familiar to anyone ruling on whether a particular medical treatment was warranted. I wrote to all our QA officers and asked why they could not just give the list to the insurance adjusters and let them look up terms they did not understand, but nobody could explain. Our own QA officer wrote back to me, saying “It’s best practice.” I wanted to write and say, “No, it’s actually worst practice.” But I knew she was just saying what she had been told to say.

Dr Feller has been in practice since she graduated from medical school in 1977. In addition to clinical work, she has served as an expert witness in civil cases and a consultant to the California Medical Board on issues of substance abuse. She is a psychoanalyst member of the San Francisco Center for Psychoanalysis (SFCP) and has taught classes for SFCP and for the UC Berkeley Extension program.