Welcome to my blog, a place to explore and learn about the experience of running a psychiatric practice. I post about things that I find useful to know or think about. So, enjoy, and let me know what you think.

Wednesday, April 26, 2017

Opioid Training Requirement

New York State recently decided that in order to address the problem of opioid abuse, all physicians (and non-physician prescribers) with a DEA number need to be trained in pain management, palliative care, and addiction. By July 1st of this year. I found out about it in the middle of March.

And it needs to be repeated once every 3 years.

The required course work covers the following eight topics:

(1)        NYS and federal requirements for prescribing controlled substances;
(2)        Pain management;
(3)        Appropriate prescribing;
(4)        Managing acute pain;
(5)        Palliative medicine;
(6)        Prevention, screening and signs of addiction;
(7)        Responses to abuse and addiction; and
(8)        End of life care.

I. Don't. Prescribe. Opioids. Period.

What I'm saying is, this training has no relevance for me, and is another example, aside from MOC, of taking time away from educational or clinical experiences that are useful to me, to do someone else's busywork.

I think whoever came up with this idea is trying to create the impression that something is being done about the opioid problem, without thinking it through. A more reasonable, and respectful approach would have been to say, "If this is relevant to your practice or work setting, then you must get this training. And if you don't have the training and you do prescribe opioids, you're in big trouble."

Here's an indication of just how poorly thought out this program was:

Providers will be required to attest to completion of the required course work or training.  The Department of Health has not yet released instructions for submitting an attestation, but has indicated that more information is coming soon.  

As I mentioned, this was back in March. There is now a way to attest, by going to the HCS portal, then "My content" --> "All Applications" --> "N" --> "Narcotic Education Attestation Tracker (NEAT)".  This is where the directions come from.

And for reference, this is the actual announcement.

There are two currently available courses that satisfy the training requirements (that I know of):

The New York Chapter of the American College of Physicians offers a three-hour online course on the required eight topics in conjunction with the Boston University School of Medicine.  This course is available free of charge to all providers.  You can view the course announcement by clicking here.

The Medical Society of the State of New York is also offering three 1-hour online courses covering the required eight topics.  The courses are free to MSSNY members and will be made available to non-members for a fee of $50 per module.

I couldn't figure out how to access this course without paying dues and logging in to the MSSNY site. But why would I want to pay $150 for a course I can take for free elsewhere?

The statute does provide an exemption from the course work or training requirement for DEA registered providers, but it's not clear to me under what circumstances, or how it can be done:

...The DOH may grant an exemption to the required course work or
training to an individual prescriber who clearly demonstrates to the DOH that there is no need to complete such training. Exemptions shall not be based solely upon economic hardship, technological limitations, prescribing volume, practice area, specialty, or board certification.

When I was making my attestation, there was a button you could press to ask for an exemption, but I didn't press it since I wasn't asking for one, so I don't know what happens when you do.

Now about the course. This is an aside, but one thing that pissed me off is that while the course provides CME credit for everyone who takes it, those certified by the ABIM can use it as SA credit, while those certified by the ABPN cannot. If that's not a scam on the ABPN's part, I don't know what is.

The first two modules were completely useless to my practice, although I found the content interesting. They cover how to:

Determine when opioid analgesics are indicated
Assess for opioid misuse risk
Talk to patients about opioid risks and benefits
Monitor and manage patients on long-term opioid therapy

One thing that struck me is that the course seems to be intended mainly for primary care providers, and it's hard to imagine when someone who is responsible for everything involved in primary care would have time to deal with pain management and potential for misuse.

The third module was useless as well as boring. It was basically just someone rattling off NY State laws governing the safe prescribing of opioids, and how to, "Appropriately document communication with patients about health care proxies and advance directives and describe the appropriate use of advance care planning CPT codes."

I dozed off several times. I still managed to pass.

So if the topic is relevant to your practice, or you're looking for some free CME credits, or if neither of these is the case but you have a DEA number in NY State, then by all means, take these classes.

Monday, April 17, 2017

House Calls

The other day, I was scooting around a Google map of Manhattan, trying to find The Doughnut Plant, which makes the best coconut cream yeasted doughnut ever. And as I was virtually strolling along 23rd street, I saw this:

House Call Psychiatrists. Hmm. I couldn't help checking out their website.

From their home page:

House Call Psychiatrists is a network of board certified and licensed psychiatrists with extensive experience making psychiatric home visits.  They are available 24 hours a day, 7 days a week for convenient and private house calls within Manhattan, Brooklyn, Queens and North Jersey.

House Call Psychiatrists offer a unique and high level service in the convenience of your home, office or hotel room. They are able to address most psychiatric issues in a timely and private manner avoiding other urgent care centers and hospital emergency rooms.

There's an interesting idea. It's a bit different from TalkSpace, a texting therapy service which I posted about previously. Some of the things I didn't like about TalkSpace were that it's not in-person treatment, and there's no delayed gratification like there is when you have to wait for your appointment.

But these are house calls. So you do have to make an appointment, even if it happens to be in the middle of the night. And it is in-person.

Here's some more information.

There are 7 psychiatrists on the team, all men. A general psychiatrist, two addiction psychiatrists, a bipolar specialist, a geriatric specialist (who doesn't seem to be board certified in gero-psych, so I guess that's why they don't call him a geropsychiatrist), a community psychiatrist, and an anxiety specialist.

Thinking about the "extensive experience making psychiatric home visits," I'm skeptical. How would they get that extensive experience? I can remember my pediatrician coming to my house, but nothing since then-who makes house calls anymore?

"Our psychiatrists have been making house calls for many years on Assertive Community Treatment (ACT) teams which are home-based psychiatric outreach programs.  They are also psychiatric emergency room physicians with admitting privileges to..."

ACT house calls seem very different to me than the house calls they're talking about here. For one thing, ACT is a team, and sees patients as such. Here, my impression is that this is 1 to 1 care. For another, most patients in ACT treatment can't afford the $500 fee that House Call Psychiatrists charge. Or $1000 from 8pm to 8am.

I'm trying to understand the model. I assume they cover for each other, and that someone is always on call.

All the the psychiatrists seem to have separate private practices that provide more typical office visits. Some of their websites indicate that they will also make house calls, but at the $500 rate, rather than their regular rates, which are less. Does this mean that the House Call Psychiatrists only see established patients? I don't get that impression.

They also offer to see patients in their hotel rooms, which implies that they may be visiting NYC, and therefore not established patients.

The house call services provided are:

This makes me wonder about liability. If they provide crisis intervention and safety checks, then they may end up seeing a patient they don't know who is suicidal. What if that patient needs to be hospitalized but refuses to go? One of the individual psychiatrist's websites states that he does make house calls, but that, "A home visit should not replace calling 911 if you are having an emergency." That confuses me.

My fantasy about this model is that some wealthy person feels like he needs to see a psychiatrist, but he is either visiting NYC, or lives here but doesn't want to go to anyone's office. I imagine this as happening in the middle of the night, with patients who suffer from insomnia (they state they treat sleeping difficulties), or who are having panic attacks. Or maybe it's during the day, but it's some CEO who wants his shrink to come to him.

I'm really not sure what to think about this model. I know I wouldn't make house calls with my patients, but my practice has a certain nature that doesn't lend itself to this model. Also, I don't fancy wandering into a stranger's hotel room in the middle of the night, knowing that there's a psychiatric problem.

Home visits are a great idea for patients who function poorly and would be lost to care if they weren't followed by an ACT team, for example. But patients who can afford $500 fees presumably function fairly well. (Incidentally, no insurance is accepted, and the fee is prepaid at each visit via credit card.)

I think that for one-off panic attacks, home visits are probably not a good idea, because they maintain the message that the patient can't manage on his own and tolerate some delayed gratification, similar to TalkSpace.

For naltrexone injection or genetic testing, maybe it does make sense for the shrink to come to your office.

For ongoing therapy, I don't know. Is there some benefit to making time during the day to travel to the shrink's office? Is there a power struggle that gets settled by default when the shrink comes to you? Does it violate the important frame of a treatment to have it in your home, or does it just create a different frame?

I have a lot more questions than answers. What do you think?