The 59.8 Minute Phone Call: Prior Authorization for Psychiatric Admissions

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.

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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.

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What does prior authorization require?

“Please enter your Tax ID number.”

            “4”

“I’m sorry, I didn’t get that. Please enter your tax ID number.”

            “4”

“I’m sorry I still didn’t get that. Please enter your Tax ID number.”

            “4”

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.

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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.

 

Resolution

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.

Tick tock.

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.

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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.

 

Looking forward

  1. There is consistent evidence that prior authorizations are always approved, so the process serves no purpose.
  2. 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.
  3. 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.

 

 

References

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

 

©2016

All images labeled for non-commercial reuse

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Andreas Lubitz and the Ethics of Confidentiality

Matt Freeman DNP, MPH

“How are things at home?” It can jumpstart a conversation about emotional health, giving the patient a chance to have control over how little or how much he or she would like to disclose. My own variation has been, “How is your mood and your stress level?” Patients often say, “the usual amount of stress.” Others become tearful. Others find an unexpected opportunity to share what is happening in their lives.

I do not know what Andreas Lubitz would have said. Perhaps he would have talked about his dashed hopes to marry Kathrin Goldbach, or his reported frustration with flying shorter fights rather than the more prestigious long-haul routes with Lufthansa. But he might have said nothing at all.

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I think back to the handful of patients I have had in my career who have been commercial pilots. I even remember chatting with one of them about his mood. He was exhausted by his schedule, his pay was abysmal, and his wife was also a pilot, thereby putting a great strain on their marriage. As is the standard of care with a patient with a mood disorder, I asked, “Have you had any thoughts of hurting yourself or others?” He said no.

 

What if he had said yes?

The rules for breaching patient confidentiality vary by country and—in the US—by state. But there is a consistent theme: plan, means, and intent. If my own patient had been specific with his plan and time range, I would have probably been able to get him admitted to mental health facility, and—in collaboration with others—most likely able to contact the airline’s medical department.

But what if he just said, “Sure, I have thoughts of hurting myself? Sometimes I wonder what would happen if the plane I was flying crashed.” I would be asking a lot of questions at that point, probably consulted with a mental health provider, but if he expressed this in vague terms—a melancholic fantasy—it would have been inadequate to sever our private doctor/patient relationship. I could urge him to see a therapist, encourage antidepressants, invite a short-interval follow-up, discussed what actions to take if he felt increasingly suicidal or homicidal, but my powers would have ended there.

All of us fear another Germanwings 9525 or Egyptair 990, but suicides are notoriously difficult to predict. If the European or American governments suddenly required all pilots to answer the question, “Are you having thoughts of hurting yourself or others?” before flying, the answer would be “no.”

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Egyptair Boeing 767-300, similar to the aircraft that crashed near Nantucket on 31 October 1999

 

Actively suicidal patients, particularly men, typically keep their plans closely guarded.  It is not too difficult for a severely depressed patient to outfox a standardized depression inventory, even the probing questions of a therapist or primary care provider.

Although the details of Andreas Lubitz’ medical history are still blurry, he could have just said, “No, I do not feel like hurting myself or others.” There is no polygraph, “trick question,” nor blood test that would have predicted a murder-suicide. Psychologists usually have the ability to estimate behavior within a 48-hour window, but that depends on the patient disclosing a lot of information.

From media reports, Andreas Lubitz had some red flags: a previous history of a mood disorder, recent treatment, a trigger (the breakup), and reportedly erratic behavior. How many pilots, truck drivers, those whose jobs require firearms or access to explosives would meet a similar description?

 

Who is the client?

My first practice out of school was in occupational medicine. I often saw truck drivers, firefighters, police officers, air traffic controllers, and others who needed medical examinations for employment. In the overwhelming majority of cases, the goal was to ensure that I “rubber stamped” the paperwork.

US law requires that any medical examination be conducted post-offer. In other words, the patient had already been given the job, and it was my responsibility to ensure that there were no barriers. The medical examination did not serve to address health concerns, prevent illness, nor screen for disease. It served an administrative purpose.

Although most patients take it in stride, some view it as a marked invasion of privacy with no benefit to public safety. It is indeed awkward, unpleasant, or threatening to answer detailed health and mental health questions, disrobe, get poked and prodded, all because an employer requires it.

Regulatory bodies, like the Federal Aviation Administration and Federal Motor Carrier Safety Administration stipulate guidelines for these examinations. But healthcare providers are faced with a dilemma: if pilot, driver, firefighter, or other examinations are part of one’s livelihood, it would be dangerous to have a reputation for saying “no.” This could lead to unemployment for the patient and a vacancy for the employer.

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The client for these examinations is not the patient himself or herself. The client is the employer and/or the government agency. Patients therefore lack the comfort of a private and established doctor/patient relationship. When a patient comes to see me on his or her own for routine medical examination, it is a “health-seeking behavior,” and he is or she is perhaps more likely to share more extensive thoughts about mental health, substance abuse, and other problems.

There is one further problem: patients can sometimes shop around. Pilots and drivers seeking medical certification can go to any FAA or DOT-approved healthcare provider. If the first examination does not go well for some medical reason, the pilot or driver can merely hope that the next examiner does not ask the same questions, conducts a less thorough examination, or the patient might just be a bit less truthful in his or her responses.

 

There is no clear flight path ahead.

Loosening confidentiality laws raises many ethical concerns. Psychological screening may be helpful but has the peril of self-disclosure: an affirmative answer to a screening question can cost one his or her livelihood.

Environmental mitigation, such as ensuring two personnel in the flight deck has the rather obvious dark side: Lubitz could have incapacitated a pilot or flight attendant seated to his left and continued to crash the plane. In the US, pilots and flight attendants do not pass through checkpoints to detect weapons in many airports since they travel through “Known Crew Member” (KCM) ID checkpoints.  In fact, many pilots are Federal Flight Deck Officers (FFDOs), who are permitted to carry firearms on board.

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Amid the grief and fear in the aftermath of the crash and its investigation the most salient call is one for dialogue. Ethicists, mental health professionals, occupational health providers, and primary care providers need to open a greater discussion about suicidal and homicidal behavior. Although a statistical rarity, the consequences are catastrophic. Now is the time to talk more about protecting privacy while protecting the public, ensuring access to care, and guaranteeing further research in suicidology.