Skype-chiatry Link

Thanks to Dinah, from Shrink Rap, for her comment on Tele Me More. The podcast includes an interesting discussion of the more technical aspects of Skype-chiatry (In the future, will people practice Skypoanalysis?). Check it out, episode #49.

Tele Me More

I want to pick up where I left off with the telepsychiatry post by looking at evidence in the literature.

One study, The Effectiveness of Telemental Health Applications: A Review  
Canadian Journal of Psychiatry | Nov 2008, reviewed 72 papers. There was evidence of success with "Telemental health" (TMH) in the areas of child psychiatry, depression, dementia, schizophrenia, suicide prevention, posttraumatic stress, panic disorders, substance abuse, eating disorders, and smoking prevention. Evidence of success for general TMH programs and in the management of obsessive–compulsive disorder were less convincing.

Another study, Outcomes of 98,609 U.S. Department of Veterans Affairs Patients Enrolled in Telemental Health Services, 2006–2010, Psychiatric Services, 2012, compared number of inpatient psychiatric admissions and days of psychiatric hospitalization among patients who participated in remote clinical videoconferencing during an average period of six months before and after their enrollment in the TMH services. Psychiatric admissions of TMH patients decreased by an average of 24.2%, and days of hospitalization decreased by an average of 26.6%.

Yet another study of 494 subjects, Is Telepsychiatry Equivalent to Face-to-Face Psychiatry? Results From a Randomized Controlled Equivalence Trial, Psychiatric Services, June 2007, compared interactive videoconferencing with face to face treatment in psychiatric consultation with brief follow-up (monthly, up to 4 months), and found equivalent improvements in function in both groups, with similar levels of satisfaction with service. And TMH cost 10% less than face-to-face treatment.

A study of 297 individuals, published in The Lancet in 2009, Therapist-delivered internet psychotherapy for depression in primary care: a randomised controlled trial, found that 38% of patients treated with online CBT recovered from depression (BDI<10), vs. only 24% of patients treated as usual by their GP. Since this study was done in the UK, I'm not sure what the usual function of a GP is there, and whether some do psychotherapy.

The China American Psychoanalytic Alliance (CAPA) has offered Skype or Oovoo training in psychoanalysis and psychotherapy to clinicians in China since 2006. It also offers low fee Skype psychoanalysis and Psychotherapy. There seems to be a lot of satisfaction with the program, with waiting lists for treatment, but there is no data that directly compares the results with face-to-face treatment.

So what do we know?

• TMH seems to be helpful in treating some conditions, such as depression and PTSD.
• In veterans, TMH has decreased admissions and length of stay by roughly 25%. 98,000 veterans-you can't ignore that number.
• TMH was equivalent to face-to-face treatment for consultation with brief follow-up, and cost less.
• Online CBT looked better than treatment by a GP in the UK.
• Many Chinese who otherwise wouldn't have access to psychotherapy or psychoanalysis are eager to have TMH treatment.

Based on this information I'd like to see a more formal study of face-to-face vs. Skype treatment for  a more general population, and for, say, psychodynamic psychotherapy, before drawing any conclusions. But I certainly wouldn't dismiss the idea of TMH entirely. 

Please note, my DSM-V survey will close on the 28th, so if you haven't responded yet, you still have time. Just click HERE.

Why Would I Do That?

Is it just me, or do other people get requests from insurance companies to accept less money for services?

It usually starts with a fax, with some indication of urgency, like, "Time Sensitive Material, Please Respond Immediately!" The first time this happened, I thought, "Oh, my patient needs some form filled out so she can be reimbursed, I better take care of it." I don't accept any insurance, but I do give my patients bills they can submit on their own, and if they need some form or other filled out, I'll do so.

But insurance companies are sneaky, and I'm glad I read the form carefully. What it said was, "You billed the patient for X dollars. We want you to agree to be paid half that, and if you sign your name, that's the most you can ever be reimbursed. And by the way, we also expect you to hand over your firstborn child."

So when I get these, I ignore them. Then the insurance company usually follows up with a few more faxes, and finally, a phone call, asking me to call them back regarding a claim. Again, they make it sound ominous.

What is going on here? Do they really think I'm going to accept half my usual fee? What incentive are they offering? I'm no expert, but I'm guessing that in any genuine negotiation, each party has to have something to offer the other. But it's just, "You accept less money, and in exchange, we give you absolutely nothing." I don't understand how they think they can convince me. Maybe it's just the wild hubris of very deep pockets who believe the future of healthcare is ONLY through them.

Has anyone else had this experience? I'd love to hear what people think the rationale is behind it.

Oh, and if you would be so kind as to take my VERY BRIEF and HIGHLY USEFUL survey, I'd be most grateful.

Dr. Tele-Love, or, How I learned to Stop Worrying and Love Skype

In the process of learning all about the new CPT coding, I also learned that phone and Skype sessions are not covered by insurance. The reasoning seems to be that they are considered substandard care. And apparently you can't cut a deal with your patient in which he will pay you for a phone or Skype session, regardless of his coverage, because a patient cannot legally agree to substandard care. Well, I guess you CAN make that agreement with your patient, but if he ever decides to sue you, you're buggered.

Furthermore, the point was made by the lawyer who gave the talk I attended that if you call your doctor to ask about something, say, at night, you don't get a bill for it. So, by extension, you can't bill for a full session that takes place on the phone.

True. Only lawyers can bill for phone exchanges. By the minute.

Personally, I don't like phone sessions. Maybe because I don't like talking on the phone, in general. I find it difficult to lose that sense you get of a patient who's in the room with you, not to mention the facial expressions and other visual cues (admittedly, these are lacking in analysis, as well).

That said, sometimes, it's necessary. A patient who needs to move suddenly, but hasn't transitioned to another psychiatrist yet. Or maybe doesn't want to. A patient who's laid up at home because of illness. Or maybe because of maternity or paternity leave. A patient who has to fly to a distant city due to a family emergency or a death.

It seems to me there are a lot of good reasons to rely on phone or Skype sessions, especially when the patient would suffer without any session at all. Are we, as psychiatrists, really supposed to spend 45 minutes on the phone with a patient, making the same comments and interpretations we would make in person, working just as hard as we would in person, and then not charge for the session?

This is a topic for another time, but why do people think it's immoral, or somehow distasteful, for doctors to want to make a living? Are we really supposed to work for free?

So what's the deal, here? Why is tele-medicine considered substandard? Is it just an excuse to limit coverage, or is it based on some factual data?

As it turns out, prison systems routinely use tele-psychiatry. I hope it isn't the case that prisoners are getting substandard care.

And you can use telepsychiatry in some states, but not others. Additionally, the use of telepsychiatry varies based on type of insurance.

For instance, medicaid covers telepsychiatry in NY.

Private insurance varies by insurer. My guess is, if there's any excuse not to cover, they won't cover.

Medicare covers telepsychiatry with some provisos. First, the consumer must be located in a "non-metropolitan statistical area", which may or may not be the same thing as a Health Professional Shortage Areas (HPSA) .

From what I can tell the consumer also has to have the session in a qualified facility, which I guess means that he or she needs to show up at a clinic or hospital, and have a qualified staff person with him or her. During the actual session? I can't figure that out.

The clinician, on the other hand, can be anywhere, even at home, but has to be licensed in the appropriate state. I assume that's the state where the patient is located.

Now, back to that "substandard care" business. If it's good enough for prisoners and people in rural, underserved areas, it should be good enough for anyone. Alternatively, it's not really good enough for anyone, but it's the best anyone can do under certain circumstances.

The next question is, "What does the literature say about how telepsychiatry compares to in-person treatment?"

Stay tuned.

DSM-5: Take My Survey, Please

Yup, it'll be here soon. I was hesitant to write about it, and I can barely call it by its name. Maybe if I don't say it, it'll disappear.
What convinced me to write about it was the dumb, completely irrelevant fact that it's going to be published on my birthday. And you can preorder it on Amazon for only $133.22.

Here's a list of some of the changes:

1. Asperger's subsumed under the heading of Autism Spectrum Disorder.
2. Inclusion of Binge Eating Disorder.
3. Bereavement exception removed from the diagnosis of depression.
4. Gender Identity disorder changes its name to, "Gender Dysphoria".
5. Addition of Disruptive Mood Regulation Disorder for children who display “persistent irritability and frequent episodes of behavior outbursts three or more times a week for more than a year.”
6. Inclusion of Hoarding and addition of Excoriation as individual diagnoses.
7. Substance Abuse and substance Dependence combined under the heading, "Substance Use Disorder."
8. Dissolution of the Multiaxial System. Axes I, II, and III are now combined, with separate notations for psychosocial and contextual factors (formerly Axis IV) and disability (formerly Axis V).
9. Chapters restructured based on disorders’ apparent relatedness to one another. These changes will align DSM-5 with the World Health Organization’s (WHO) International Classification of Diseases, eleventh edition (ICD-11).

I've been wondering about why I'm so wary of this new manual. Maybe because it's the "bible" of psychiatry, and reimbursement will be based on it, despite the sometimes nebulous scientific underpinnings of some of its content. Or maybe because it has the potential to pathologize normal elements of the human condition, such as grief following a loss, or temper tantrums during childhood.

And I wonder which of the changes will do the most harm. And which the most good.

What do you think? Please take the following 4 question survey. I'll post the results, and write in detail about whichever changes are the best and worst, in your opinion.

SAFEty and The Cannibal Cop

For those who didn't follow it, the Cannibal Cop is the case of former NYPD officer Gilberto Valle, convicted on March 12th of conspiring to kidnap, rape, murder, and eat several women, including his wife, as well as illegally accessing a national crime database to research his potential victims.

The thing is, he never actually did the things he was convicted of conspiring to do. He fantasized. He plotted. He even went so far as to show up on the block of a woman he had agreed to kidnap in exchange for $5000. But he never did so. He only conspired to do so.

Am I glad he's behind bars? Yes I am. Do I believe he would have acted out his ghastly fantasies? Yes I do. Am I justified in feeling this way? Not sure.

This case begs the question: How do you differentiate between a fantasy to hurt someone, a wish to do so, the intention to do so, and the acting out of the fantasy?

This is the same question that lies at the heart of NY's SAFE act, which requires that certain mental health professionals, including psychiatrists, "Report to their local director of community services ("DCS") or his/her designees when, in their reasonable professional judgment, one of their patients is 'likely to engage in conduct that would result in serious harm to self or others.'" The information then gets forwarded to the Division of Criminal Justice Services (DCJS), who determine if the patient has a firearms license. If so, it's either suspended or revoked. If not, he gets put on a list so he can't get a firearms license.

There is so much wrong with this act, it's hard to know where to start.

The New York State Psychiatric Association (NYPSA) has taken issue with it because of its language. SAFE claims that the standard to use for determining danger is the same as for deciding whether to hospitalize a patient, or to call the police, or contact a potential victim, as in a Tarasoff situation. But this standard already exists in the law, and we know that if we think a patient is genuinely dangerous, we should do something about it. And that something shouldn't be contacting the local "DCS".

In other words, if the danger is immediate, I shouldn't be worrying about putting the patient on a no-firearms list, I should be hospitalizing him, or calling the police, or the potential victim. And if the danger is not immediate, how am I supposed to know if it's serious and real? It's like that Tom Cruise movie with the "precogs" who predict future crime.

I consider it my job to recognize patterns of thinking and behavior in my patients, and to point these out to them, so they can use that information to their benefit. But that doesn't mean I know what they're going to do down the line. And SAFE is asking me, no requiring me, to point out that information to a government agency, to be used to the patient's detriment.

Sure, there might be some clear cut cases. Shrink Rap mentioned the hypothetical case of a patient who tells her he's hanging around with his Al Qaeda buddies and taking flying lessons (sorry, I couldn't find the exact post). Okay. I can see that. But most of the time it's not gonna be that clear.

And what population are we talking about? Acutely hospitalized psych patients? Prisoners with co-morbid psychiatric diagnoses? Psychopaths? Neurotic outpatients? Dual diagnosis patients? These are very different groups.

I could understand if it were someone else's responsibility to report the patient. Say, the ER, after I've sent the patient there for evaluation, because I think he may hurt himself. Or the inpatient unit if he's admitted. Or the police, if I contact them because I think he's going to hurt someone besides himself. At that point, the immediate danger has been addressed, and then there's time to think about how dangerous this person is likely to be in the long run.

Okay, so let's assume, for the sake of argument, that I know for sure that my patient is going to do something dangerous down the line. And I report him the way I'm supposed to. And he loses his right to bear arms. He still hasn't lost his right to walk into Williams-Sonoma and buy himself a nice, big, sharp Santoku knife. Or to mosey into Costco and buy himself two giant bottles of tylenol.

Why create useless legislation? Oh, yeah, because they're politicians running for office.

Another BIG problem with SAFE is the issue of confidentiality and how it affects trust. Patients sometimes have thoughts about hurting themselves. If you've known your patient for a while, you can usually tell how serious a threat it is. If you don't know the patient, then you really can't tell, and you're now in the position of revealing something significant about her to the government, something that will affect her civil liberties for the rest of her life.

Will someone who needs psychiatric care hesitate to get it because of this possibility? I'm guessing yes. But then, of course, I can't predict the future.

Template

There seems to be a frenzy of questions about CPT coding floating around cyberspace.

One issue that's been popping up is the split in billing. Some people are doing it, with a rough guideline of 60% CPT, and 40% E/M. Others are not. Some claims have already been rejected because of the absence of split billing.

There are all kinds of questions about what constitutes a 99212, or a 99215, arguments that confuse the value of our work with the question of which is the appropriate E/M code.

People, they're not related.  The E/M code is what you do to satisfy some sub-regulation of a regulation. The value of our work is infinitely more important, and correspondingly less understandable to anyone whose job it is to reimburse the work.

If you're still confused, read my E/M posts more carefully, because I couldn't possibly be anything but crystal clear in my exposition.

But enough about me. What do you think of my template?

Actually, it's not my template-it was developed by a colleague of mine, with some input and graphic design updating from yours truly. Also, you haven't seen it yet, so why am I asking?

First a disclaimer. Since the template was devised last December, I have made a lot of my own changes to this template, as has my colleague. I'll get to the ideas behind the changes, but I wanted to present it in an early version, so people can use and modify it as they see fit.

Another disclaimer: This template has not been endorsed by any agency involved in CPT and E/M coding, official or otherwise. It is not a guarantee of reimbursement. And I am not responsible for the fact that it may not be the right way to code. So you can't blame me, or my colleague, if you use it and something goes wrong.

I just find it convenient for my needs. And I'm presenting it with my colleague's permission. So here it is:

These are some of the changes I've made and why:

1. I've added a section entitled Plan/Discussed with Patient. I did this because otherwise, if I look back at the note a year after it was written, I won't be able to figure out what I did, or what my reasoning was.

2. I left the ROS section blank, to be filled in, because as it stands, it only deals with one organ system, and there are often others that need to be commented on.

3. I deleted the "severity" blurb under HPI, because severity is only 1 of the elements of history. I replaced it with: 

Location Quality Severity Duration Timing Context Modifying Factors Assoc. Signs/Sx

to remind myself of other HPI elements.

4. I removed anything that was there to remind me of what I need to satisfy that component of the note, e.g. "Problem Focused 99212".  I felt that should be in my head, not the note.

5. The template was originally designed to fit on one page, which my colleague prints out. I fill it out electronically, so I expanded it to two pages.

4. I added some additional elements to the CC and Psychotherapy sections. My colleague has since added others.

Bottom line: This is a work in progress, and it's helpful in some ways, and a royal pain in others.  You can use it, or elements of it, if you find it helpful. Please use appropriate attribution.