Yes, if we are ever to have improved healthcare at lower cost
By: Les Ruthven, Ph.D. Clinical Psychology / Health Consultant
Email: dr.les.ruthven@gmail.com
Blog: www.ruthvenassessments.com
With the exception of medical doctors all state governments across the U.S. define the lawful practice of each health profession and restrict these professions from delivering services outside of their training, which is certainly a sound law to protect those accessing health services. As a psychologist in Kansas, for example, I could employ neuropsychological testing to diagnose a suspected left temporal brain tumor but of course it would be unlawful of me to conduct brain surgery on any patient and rightly so. If I had conducted brain surgery I would have been violating the Kansas psychology licensing law and I would have been invading the legitimate turf of qualified brain surgeons.
From the author’s 22 plus years of critically examining the efficacy of what I call “everyday” healthcare of both psychiatric and “medical” services I would recommend that the employer self-insured health plan not reimburse for the following healthcare services by physicians because (1) physicians do not have the necessary training and expertise to competently deliver the service in question and (2) less costly and proven effective services by other health professionals are available to deliver the service. In these cases of restricted practice by employer self-insured plans the physician must refer the patient to the appropriate carveout to arrange appropriate care by contracted qualified health professionals in the carveout.
Primary Care physicians (non-psychiatric physicians) are not reimbursed for the diagnosis and treatment of all of the mental disorders and physicians must refer these patients to the appropriate carve out for referral/treatment. The carveout has sole responsibility in making referrals to psychiatrists. Physicians, during the clinical internship, have a 6-week rotation in psychiatry in which psychiatric medications provide a great deal of the training in psychiatry. General physicians have only one tool (i.e. drugs) to treat the mental disorders while these disorders require non-drug services by non-physician professionals such as psychologists and clinical social workers.
Physicians are not assigned responsibility for diagnosing and treating insomnia with drugs (benzodiazepines and others) and must refer these patients to the carveout for diagnosis and appropriate (non-drug) treatment. Sleep problems can and do occur in emotionally “normal” people whose insomnia is fully responsive to a sleep-hygiene approach. However, sleep problems can be a symptom of a variety of mental disorders and general physicians are not trained to make this diagnostic determination. Also, too many physicians allow patients to become addicted to these drugs.
General physicians should not be allowed to prescribe weight loss drugs to patients and must refer these overweight/obese patients to the appropriate carveout for instruction in changing one’s eating behavior. The patient’s physician of course continue to provide medical services to these overweight patients but not weight loss treatment.
General physicians are not allowed to treat chronic pain with opioids, which is the recommendation of the CDC; chronic pain reflects both biological and psychosocial factors and must be treated comprehensively. These patients are referred to the appropriate carveout. Comprehensive treatment of chronic pain may well turn around the 500,000 and growing opioid death rate.
General physicians may not refer a back pain patient for steroid injections since the FDA finds no evidence of proven effectiveness or safety. In comprehensive treatment of chronic back pain biological and psychological factors must both be addressed and physicians must refer these patients to the appropriate carveout.
The health plan is aware that patients with serious chronic pain have important emotional, psychological, and life situation factors that contribute to their pain and the physician must refer these patients to the carveout for assessment and any treatment of these non-organic factors in chronic pain.
Cognitive impairment (Ci) is a very pervasive health problem in any health plan and can arise from a large variety of sources such as many forms of environmental pollution, many brain impairing prescription drugs, as well as a variety of neurological disorders. Traditionally physicians have had sole responsibility to arrange diagnosis and treatment for cases of suspected Ci; these cases require physician referral to the appropriate carveout to manage appropriate diagnostic referral/treatment or rehabilitation for these brain impaired patients.
The above list of restricted physician practices comes from the examination of the sound health literature and the list is hardly exhaustive but added restrictions should also be based on the available sound research.
Despite these restrictions on physician practices physicians will still have the major role in providing healthcare than any of the other healthcare professionals. However, the services that physicians provide will be more in line with their training and expertise than currently.
Explanation of carveouts in health plans: A number of health plans used to have carve outs such as behavioral health and a cancer carveouts as two examples. In 1987 I was the first psychologist to create a national BH carveout managing outpatient and inpatient mental health and substance abuse services in our Preferred Provider Organization (PPO). Those in the plan could seek a provider on their own which covered usually 50% of the cost or they could call my company (Preferred Mental Health Management, Inc.) and have 80% of the cost covered if we managed their care. We were unique in that the caller had a telephonic assessment by a senior level psychologist at company headquarters and following this the caller was referred to a specific psychologist, clinical social worker or a specialist in addictions in our carefully selected PPO. Those in the inpatient and outpatient PPO discounted their services to the patients and the health plan. The reduced costs to the patient being treated typically resulted in increased utilization of the numbers using mental health services. PMHM psychologists had to approve all hospital admissions and length of stay and such management reduced a large employer’s hospital stay of 9.5 days before PMHM to less than 5 inpatient days, which resulted in reduced cost of 6.5 million dollars annually. Psychiatric hospitalization for patients who are dangerous to self or others is required to stabilize and prepare the patient for outpatient treatment.
Apparently the health insurance industry did not like the carve outs of the 1990s, perhaps because of reduced revenues to the insurance company, and many bought these carveouts to keep all services in-house. My company lost a million dollar a year client because the insurance company would not allow a behavioral health or other carveouts in their insurance plan. These carve outs, made up of experts in the specific health area, need to be brought back to the market to improve the quality of healthcare.
The author is open to helping psychologists interested in marketing to employer sponsored employee health plans one or more carveouts as in the above.
