Matt Freeman DNP, MPH
In clinical practice with adolescents and young adults, decisions about psychiatric admissions surface about once or twice a month. These are never taken lightly.
Safety invariably predominates. Although an organized and imminent suicidal plan is the most common reason for admission, sometimes the patient has experienced a manic episode that warrants stabilization. Others may be experiencing psychotic symptoms that but them at risk for harm to themselves or others.
Despite the often grim reality of psychiatric units, the goal is to protect life. Most of the admissions in my career have been brief: perhaps a 72- to 96-hour opportunity to prevent a suicide or accidental death, to ensure adequate medication, and to be as certain as possible that appropriate care is available after discharge.
The decision to admit is complex. In my experiences, it was usually a collaborative decision by a psychiatrist, psychologist, primary care provider, the patient, and the patient’s family.
The Goal of Voluntary Admission
Involuntary or “civil” commitment is sometimes avoidable. If a patient resists admission, one can take legal steps to argue that an admission supersedes the patient’s wishes. But this “buys” only 72 hours, and can create an adversarial relationship between the patient and those caring for him or her.
Interestingly this is sometimes referred to as a “5150” on television and movies. In fact, this is a reference to California law, the Lanterman-Petris-Short Act, which is section 5150 of the California Welfare and Institutions Code. Each state has its own name or number for involuntary confinement, but those who write screenplays and television scripts are sometimes unaware that this term is specific to California.
The process for a 5150 and its analogues can be laborious. For meaningful ethical and constitutional reasons, there are specific criteria and processes for obtaining a 5150. To my recollection, I have only ever done it two or three times in 13 years of practice.
A voluntary admission carries its own burdens. The patient and his or her family may have agreed, but one then has to find an available psychiatric bed. This can mean calling hospitals—sometimes in distant locales—to find an available bed at a hospital that accepts the patient’s insurance.
As is the case with just about everything in health care, these discussions and phone calls always seem to occur late at night, after an arduous day of assessing a patient who warrants admission.
Now it takes even longer.
Insurance carriers have started mandating prior authorization for psychiatric admissions. In a study published in the American Journal of Emergency Medicine, the average time spent on the phone with the insurance company was 59.8 minutes.
That is 59.8 minutes with a sobbing, suicidal patient in the room next door. That is 59.8 minutes of frightened, tired parents, terrified that their son or daughter could end his or her own life or become a danger to others. That is 59.8 minutes when that patient could be en route to a hospital where his or her safety and access to care could be guaranteed.
Fifty-nine point eight minutes is the mean. The authors of the study reported one case in which the prior authorization process took four and a half hours.
It is even more absurd: of the 53 cases in the study, prior authorization was granted 100 percent of the time.
Healthcare providers take careful notes, elaborate documentation, and collaborate extensively about psychiatric admissions. But insurers have somehow convinced themselves that we are less than diligent.
What does prior authorization require?
“Please enter your Tax ID number.”
“I’m sorry, I didn’t get that. Please enter your tax ID number.”
“I’m sorry I still didn’t get that. Please enter your Tax ID number.”
After the interactive voice response menu finally recognizes my voice or phone keypad entry, I wait on hold.
“Hello!” a pleasant voice, usually with a thick accent, will answer. “What is your Tax ID number?” After repeating it twice, I provide my name. For whatever reason, names and titles do not translate easily and I am usually referred to as “Dr. Matt.”
“And how are you doing today Dr. Matt?”
I could easily reply, “volatile, rabid, and angry,” and the representative—reading from a script—will say, “That’s great to hear!”
After providing the patient’s ID number, birth date, and address, I am usually told that I have called the wrong number, even though I specifically dialed the special number for “behavioral health.”
After hold music, “What is your Tax ID number?”
And it continues.
Sometimes the system just hangs up when I am transferred. Sometimes it starts back at the same number.
If I ask for a supervisor, the agents usually say that they do not have a supervisor, or that no supervisor is available. Although I try to be as polite as possible, I once asked, “You have no boss? Nobody who oversees your work? Nobody who coaches you?” The agent said, “No.” Another replied, “I have a supervisor, but she won’t be able to help you.”
The patient in distress is quivering in a room next door.
It gets more complicated.
Insurance plans are often specific to a particular state. A patient might reside in Oregon, but his or her insurance plan is designed for residents of Delaware. The patient’s parents or guardians might work for a Delaware-based company.
When it is an out-of-state insurer, the phone response is:
“I’m sorry, I didn’t recognize that Tax ID number”
Of course you did not recognize it; I am not in Delaware. After dialing as many random keys as possible, I might be fortunate enough to get a live person.
“Oh, we have to enter you in our system.”
This requires my name and professional details, license, address, FAX numbers, and—you guessed it—my Tax ID number. In some cases, I will get the absurd response that I should receive a fax in two to three business days.
In several cases, I was told that since I was not in that particular state’s network, they would be unable to assist me due to HIPAA. After hanging up and calling again several times, I finally reached someone who did not claim such a ridiculous excuse. The sharing of confidential information would have been by me, and the Health Insurance Portability and Accountability Act of 1996 explicitly permits information sharing with an insurer. “HIPAA” just sounded like a good answer to that phone agent.
After that step is completed, I am given another number to call.
Tick tock. Tears continue to shed. Nervous parents clutch paper coffee cups. Sometimes agitation ensues, and the patient might start to back out of the idea of a voluntary admission.
Most insurers offer the opportunity to obtain prior authorization by means of a web site. But this is usually an exercise in futility. One has to register for the web site if it is an out of state insurer, inviting a response “within seven business days.” In other cases, the site will process everything, and then offer a fax response “within one business day.” Other sites fail to recognize the patient’s ID number.
In some cases, the phone representative at the Overseas Call Center (OCC) will grant the prior authorization. In others, a “peer to peer” consultation is required.
Amusingly, the phone representative transfers me to another call center that handles appointment scheduling. An appointment for me to consult with a physician or nurse about the patient, presumably during the subsequent few business days.
Sure, I am happy to clear my schedule for non-reimbursed time to chat with someone who will invariably approve my request. That is a sound use of resources.
The “peer to peer” healthcare providers usually sound as if their eyes are rolling when I do talk to them. They approve the authorization, sometimes with their apologies for the bureaucracy.
What are the principal problems?
- Delay in treatment in potentially life-threatening circumstances
Spending four and a half hours on the phone is an astonishing waste of a clinician’s time.
- Lost revenue for everyone
A clinician makes no money on the phone fighting through broken phone trees. And the insurance carrier is paying for its representatives and “peer” reviewers for something that they will always approve.
- Poor public relations
Insurance companies are not known for their favorable image with the public. When parents of a suicidal young person learn that treatment is forestalled because their child’s primary care provider is on the phone for an hour, it does not look good for the insurer.
Is Prior Authorization Always a Bad Idea?
Insurers sometimes have decent reasons for requesting prior authorization. For example, it is not unusual to find clinicians who are overzealous about ordering expensive tests or medications when effective, more affordable options exist. Some are overly eager to order MRI examinations for back pain when patients do not meet the medical criteria for such an exam. Others might prescribe a new, shiny drug in lieu of something safe, effective, and generic.
Some of the web-based prior authorization tools like “covermymeds.com” work for multiple insurers, and are not too burdensome.
In Israel, for example, the sal or “basket” of readily available drugs for primary care providers is more limited than in the United States. Azithromycin, known with immense popularity as Zithromax or a “Z-Pack” is not in the sal. American prescribers are notorious for prescribing azithromycin for people who do not need it: particularly those with viral infections who will only gain side effects and bacterial resistance form azithromycin. If one wishes to prescribe it, the Israeli system requires prior authorization by an infectious disease specialist. It is a reasonable means of protecting antibiotic stewardship.
In other words, American clinicians have the extraordinary freedom to prescribe unnecessary antibiotics with impunity but are barricaded from a psychiatric admission for a young person in immediate distress.
- There is consistent evidence that prior authorizations are always approved, so the process serves no purpose.
- Allow patients to be admitted for 24 or 48 hours without prior authorization. This eliminates delays in care but still allows insurers to collect information they deem necessary.
- Streamline phone trees and online systems. Overseas call centers may save on labor costs, but the amount of time spent on language clarification, dysfunctional voice recognition software, and multiple transfer upon transfer to different representatives probably exacerbates the cost to the insurer.
Funkernstein, A, Harstelle S, & Boyd JW. Prior authorization for child and adolescent psychiatric patients deemed to be in need of inpatient admission. American Journal of Emergency Medicine. 2016: 27 February. http://dx.doi.org/10.1016/j.ajem.2016.02.027
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