Spring 2002

Mental Health

**Establishing frisk of outpatient management

**Fraudulent documentation

**Physician versus insurance company liability 

John is a 63-year-old man who has been seeing a psychiatrist, Dr. Offenbach, for two years because of an accumulation of life stresses. John’s managed care insurance plan permits 20 psychiatry outpatient visits per year. John began to see Dr. Offenbach when he lost is job as a midlevel executive for a large corporation and was unable to find comparable employment or succeed in a lawsuit he filed against his employer for age discrimination. During this time, his wife developed cancer and deteriorated rapidly.

On Monday morning, weeping uncontrollable, John called Dr. Offenbach at home. His wife had dies the previous Wednesday and was buried on Saturday. “Life isn’t worth living,” he said over and over again. John refused to come to the psychiatry emergency room but agreed to meet Dr. Offenbach in her office. When he arrived unshaven and disheveled, John was inconsolable, and when asked what he was going to do, he replied, shaking his head, “I’m not sure, I’m not sure. Things just keep getting worse and worse.” Although John has denied a suicidal planning the past, Dr. Offenbach is aware that her patient is an avid hunter and owns a rifle and would like to admit him to the hospital for close observation. Before it will agree to pay the hospital bill, however, John’s managed care company must approve the admission and Dr. Offenbach will therefore need to carefully justify this admission in order to obtain this “precertification.”

Several months ago, another managed care company refused to certify an admission for Dr. Offenbach’s patient, Karen, a woman with borderline personality disorder, who had recently broken up with her boyfriend. Karen had a history of impulsive behavior and had threatened suicide on several occasions. A psychiatry resident it eh emergency room had told the opnay’s case manager the patient was “suicidal,” to which the case manager replied, “How is she suicidal?” The resident wavered, saying, “she’s not sure what she’s going to do, but I’m sure she’s going to do something: Precertfication was refused, and the patient was referred for outpatient follow-up with Dr. Offenbach. Karen went home and called Dr. Offenbach at her office, stating she had just taken 50 Pamelor [nortriptyline].” Karen’s mother took her to a local emergency room, where appropriate measures were taken. Although it appeared as though Karen had exaggerated the number of pills taken, she was admitted to a medical ward and was discharged in good physical condition.

Dr. Offenbach had discussed that “close call,” with several of her colleagues, who had ad similar experiences and were increasingly disgruntled about managed care. Now she wants to take no chances, and tells the company’s case manager that John has a clear plan, has stated that he owns a gun, and intends to shoot himself. The admission is approved. Jon is admitted and is treated with antidepressants, sedation, and psychotherapy.

Continued hospitalization requires preapproval every tow days; without this approval, the hospital will not be paid. The managed care company uses published criteria, which require discharge to home or outpatient day program by Day 4 if the patient is “Capable of activities of daily living,” and is “neither suicidal or self-mutilative.” By Day 3, John is calmer and has taken a shower. “I’m still not sure what I’m going to do,” he says. Dr. Offenbach feels that patient should be observed for a while longer while psychotherapy and medications continue and instructs the hospitals’ case manager to tell the company the patient is sticking to his suicide plan. The doctor is concerned about he patient’s risk and documents her concerns on the chard and adds, “patient still suicidal.” 

1. Given the limitations and potential conflicts of interest inherent in a managed care setting, are there particular ethical obligations physicians owe to patients?
2. If John were discharge d in his current condition due to the decision so f the managed care company, and he then went on to take his own life could the managed care company be held accountable in some way?
3. Has any activity occurred on the state or federal level to address the concern raised by patients and providers about the actions of manage care organizations?

From: Ahronheim JC, Moreno JD, Zuckerman C. Ethics in Clinical Practice, 2^nd Edition. Aspen Publication, Maryland, 2000.

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