It's been a while since I posted something on a clinical topic. Most of my clinical "sharing" has been through the Physician's First Watch project – which continues to go very well.

Today's Docnotes topic: Amphetamine Psychosis. Not much research on this. I was in the unfortunate position of missing the diagnosis about two weeks ago .. and then recognizing it about 1 week ago. Here's a short review of the events .. so perhaps it doesn't happen to you. I'm now be more careful to screen for it in adults who are being treated with stimulants for ADD.

Not much out there, as I mentioned .. but here's a link to the cochrane review: Treatment for amphetamine psychosis .. and here's a link to a case report in pediatrics.

OK .. here goes.

~30 YO WF with a long hx of under-achievement and disorganization – in life and cognition. I had suspected that ADD was a component of her difficulties, and had known her for years. I loaned her a copy (the last one – as we rarely get them back!) of Ned Holowell's wonderful Delivered From Distraction and she took it home to read.   About a month later, she returned and wanted to discuss treatment options. We chose a short-acting stimulant – at a low dose – to see how things went. I often do this – and scheduled a follow-up for two weeks. 

No-show for the two-week visit, but I was informed by a family member that things were going very well.  Taxes paid for the first time in years, work and life in better order than ever.

At about 1 month – we saw each other in the office and she confirmed that things were going great.  So great, in fact, that she had developed a bit of a "sixth sense" about things.  Family life was great, work was great, and her "sixth sense" had enabled her to be able to help others with their problems too.

I wondered a bit about the "sixth sense" but it seemed that things were going so well, we would continue with the treatment and see how things went.  Scheduled a follow-up for another month.

Two weeks later, she called.  In a 90 minute phone conversation (with apologies to my wife for my late arrival home again), it became clear to me that things were not right.  The "sixth sense" had developed into true clairvoyance.  She was stopping people in the street and "connecting" with them – telling them the truth about themselves, connecting with long lost relatives.

What was impressive about her psychosis is that she felt that it was the first time that she was allowing herself to be herself – without censorship of the thoughts or ideas she has always been thinking .. but never felt comfortable expressing. 

The story ends well.  With the help of her (worried) husband – we had a visit in the office.  Turns out that she had been taking the medication in much greater doses than prescribed for the previous 15 days (some is good – more is better?  Nope).  We stopped the medication, and monitored her closely.  She's now back to "normal" and we'll work on other methods of treating the ADD very soon.

It's well documented that primary care physicians help many of our patients with psychosocial problems. Our medical student today was surprised that nearly all of the patients had some such issues that we addressed.

One middle-aged man who suffers from attention deficit disorder was a Polaroid photograph of a man depicted in one of the later chapters of Edward Hallowell's book "Delivered from Distraction" His wife is so angry at him for all of the unfinished tasks in good intentions, and he feels so guilty for his years of inability to "function normally" that it is nearly destroyed their marriage. Medications are helpful, counseling is helpful, but this disorder has certainly taken its toll and he is now working very hard to learn new skills and applied his extraordinary aptitude to this persistent problem.

And an elderly man with depression who told me that "I never thought that I would be someone who was referred to a counselor for problems with my mental health." and as I (insensitive Lee) explained to the medical student who was listening to her conversation, I suggested that he was of the generation that considered counseling to be unusual and abnormal. Turning to her, I asked what percentage of her medical school class had likely sought the assistance of the counselor. She surprised me by responding with what I expect was a rather accurate response "50%." All of this led to a rather interesting conversation of normalcy and "what is normal." he described his personal efforts and hopes that he would be able to "self analyze" his predicament and then give himself advice for how to resolve things. I took a rather different perspective. "I don't speak Portuguese. It's not because I'm stupid or weak or abnormal. It's just that no one taught me.

He looked at me funny.

"So couldn't it be just that you haven't learned the skills to help you with this?"

That's how I see counseling. Patients who do well with counseling are patients who learn new skills to help them cope with the enormous pressures and problems they encounter in their daily lives. By marketing counseling in this way, I think it makes the whole experience more palpable for patients.

Unfortunately, it doesn't always work out that way. Some counselors are excellent and share this vision and expectations. And other counselors (at least as my patients report the interactions) take notes, listen, interject their own personal agendas and so on. So I'm never quite sure what my patient will be getting on and make such a referral. Most of the time things go very well. And that's good.

So Mrs Smith ("Not her real name") sends her physician a printout from the Internet (or a clipping from a magazine or a flyer or whatever) describing JOE'S SNAKE OIL which she is certain has saved her life and lowered her cholesterol and made her hair grow longer and now she is exercising and dancing and running around the house and she is happy for the first time in years and she is eating better and no longer has to take her blood pressure medicine and so on.

And .. yeh .. no kidding .. it all happened and the BP is down and the cholesterol is better and the diet is MUCH improved and the exercise is happening and the smoking stopped and …

So the physician wrinkles his nose and wonders what to do.  Clearly (to him) the changes are from the improvments in lifestyle.  Better living "cured" the patient of the ills that were all likely due to her previously rotten lifestyle. 

To her, the changes in lifestyle couldn't have been possible without Joe's Snake Oil and now she is certain the the physician is going to embrace this and sell it to all of his patients and everyone will be happy and then THEY too will live better and go off all of their medications.

But he's one of these "I Like EBM" nuts and there were no confidence intervals or p values or likelihood ratios or even NNTs in her literature so … this ain't really flying his kite at all and he's thinkin he's going to set her straight and tell her right out that it wasn't the Snake Oil at all .. but her own good choices and actions that made her do so well.  Had nuthin to do with the Snake Oil.

(He thinks fondly of Dumbo's Magic Feather .. which enabled him to fly .. until he realized that he could fly without it too!)  …

But maybe that's silly of him to "set her right." 

What does it matter?  So long as Joe's Snake Oil won't hurt her … who cares if she belives it helped her so much.

He does.  He hates to see her waste her money on such a silly thing.

But it's a lot less than those $30 co-pays .. which really add up — eh?

…

Where's MY magic feather?  I haven't been able to fly since I lost it!

A colleague passed away this week:

Albany, N.Y. : Timesunion.com : Obituaries

He was the victim of a terrible disease called depression, and I didn't know it – nor did most of his colleagues. He was a wonderful physician – and was adored by his patients, medical students, residents and colleagues.   A careful, thoughful physician, I always found him easy to speak with – and (unlike some specialists) he valued the opinions and contributions of primary care physicians.

Some would say that health care providers make terrible patients.

They're missing the point. It's very hard for physicians to reach out to other physicians in a trusting way. It's common for physicians to hesitate seeking treatment for psychiatric illness due to a misperception that such treatment will become public knowledge or will impact their status on hospital staffs. Last week, I was asked by a patient not to enter the Zoloft prescription I was writing into her chart. I told her that I couldn't do what she was asking, and I addressed her concerns that the entry in her medication list would make her "look crazy" to anyone looking at the record.

Yet it's been hard for me to address similar concerns from physicians in such a convincing way.  They must respond to annual questionnaires from the hospitals where they admit patients, and they must list all medcations and medical problems they are being treated for. While such information is strictly confidential, many physicians know that their peers who sit on the credentialing committee will see this information.  One physician patient told me that – while he would like to be treated for a given problem – he would prefer I NOT treat him for his – as he wold have to report this treatment.

Something is wrong when the people who are supposed to care for everyone else cannot get care for themselves because of such fears. Could our colleage have been helped? I wish I knew. Here's a little news blurb on the topic of physician suicide.  It's the leading cause of "early death" in our profession.

Today – like many days – was psychiatry day.  Here's a nice set of algorithms from Primary Care Psychiatry. 

Anxiety and depression are commonly encountered in primary care – and while I am certain that we underdiagnose these problems, i'll bet we overdiagnose them too – especially when we don't connect well with our patients.  It's not uncommon for me to meet a new patient with a longstanding health problem who has been (unsuccessfully)  treated with an SSRI by their previous physician for somatic complants with no clear cause.

I'll admit that sometimes the actions of the previous physician make sense to me – the patient with an anxiety disorder or depression who has persistent somatic complaints may very well be depressed or anxious – which is more likely the root cause of the fatigue or muscle pain than some rare biochemical disorder.  Yet it's a tough line to walk – and sometimes people see a physician's attempt to treat depression as a cop-out in the context of a persistent somatic problem that feels (and is) very real. 

There's no easy answer here.  Depression is not a wastebasket diagnosis that we should throw at our patients when the TSH turns out to be nornal.  Then again – we should not ignore it.    Building an alliance with our patients to build a good understanding and shared decisionmaking can avoid such either-or dillemas. 

I won't say I'm always successful at this  .but I do try my best to walk this line in a respectful, caring manner.

A few weeks ago, I pointed to an article on billing for mental health services in primary care.   I was surprised that the author suggests that primary care physicians can use 908XX  CPT codes.  I've never done this, and asked our medical director what he thought.  His initial response:

…. many/most of our health plans will likely not reimburse us for these services because of their requirements that mental health diagnoses be treated within their mental health network. If Medicare were to pay, they would pay at the reduced mental health rates. So, it doesn't sound like a good idea any way you look at it.

My morning project confirmed his thoughts .. and then some.  It gave me a little glimpse of what our billing staff attempts to deal with on a daily basis … and is a great example of why our health system is simply broken.

Better rewind to March, 2003 to catch you up.

• I see a patient with bipolar disorder in the office for a follow-up visit.  I had initially referred him to a psychiatrist for help in confirmation of the diagnosis, and support in medication selection.  After about 8 months, the patient was doing very well and asked if he could follow-up with me for this problem and monitor his medication levels, etc.  Both the psychiatrist and I felt that this would be just fine.
• So our first follow-up visit went well, and I coded the visit with a 99213 and an ICD-9 code consistent with the diagnosis.  Bill goes out for $74
• The bill went to the primary insurance company, but since an ICD-9 code that was consistent with a mental health diagnosis was used, the charge was denied.  The patient's insurance coverage dictated that all mental health benefits be managed by another company rather than the primary medical insurer.  So after our billing department got the denial, the bill was re-sent to the other company.
• Since the other company doesn't have me on their list of  "in-network" psychiatrists, the charge is applied to the patient's deductible.  (not yet met) So nothing is paid.
• Now it's 6 months later … 11/03
• Our billing office sends patient a bill.  12/03
• Our billing office sends patient a bill.  1/04
• Our billing office sends patient a bill.   2/04
• Patient is mad.  Has called us a few times …. we call insurance company … patient told by our billing office that this is not paid by insurance since deductible for mental health services wasn't met .. so they need to pay the balance of $59 ($15 already paid .. patient's co-pay).
• Patient calls insurance company – who tells patient that physician made billing error, submitted wrong code.  If we re-submit with "a medical code" then bill will be paid.
•  … more of the same … now it's 6/22/04 .. my day off .. billing specialist asks me if I want to write off the $59 since the patient is on the phone and still very angry about bills from us that keep coming.
• I have 10 minutes at home to call insurance company.  I don't think I made any error.  Coded accurately for a diagnosis that is appropriate to be managed in primary care.  It's not like I coded for a psychotherapy CPT (I'd never DREAM of making that mistake .. despite the article in PCC!)
  •    Call provider services number.  Navigate through voicemail.  Enter my tax ID number, patient's SSN, patient's date of birth.
  • Wait on hold 15 minutes
  • Talk with human who tells me I have to call another number.
  • Repeat process above – waiting on hold  only 10 minutes this time
  • Human answers … reviews bills with me and suggests that we re-submit bill with a "medical code" such as insomnia or fatigue.  She explains that the psychiatric ICD-9's go automatically to the mental health services company.
    • So any time I code for depression or anxiety you won't pay?
    • No .. we'll pay for it just fine
    • But this got denied
    • Yes .. because the mental health services company didn't deny it
    • It sure feels like they denied it.
    • Well, they didn't send it back to us
    • Why not?
    • Because they applied it to deductible since you're out of network
    • No I'm not .. I'm in your network
    • But your not in their network of psychiatrists.
    • Of course not
    • So If they had denied the claim AND sent it back to you .. you would pay it?
    • yep
    • OK .. how can we make them send it back to you
    • why don't you try re-submitting it.
  • Re-submission was not something I wanted to embrace and I politely explained that I was not hanging up until we had all figured out a solution right now .. rather than rolling the dice.  After about 15 minutes on hold .. and some more conversation, we got the representative from the other company on the phone.  She couldn't help us, and felt that everything had been done properly and that the patient was responsible for the balance.  I suggested that this was simply crazy, as it would mean that primary care physicians would never be paid for mental health ICD-9 codes.
  • At this point, she volunteered the same suggestion the other representative had shared: I should be using a "medical" code describing the symptoms rather than a more accurate (and legitimate) mental health code.
  • I suggested that this would be fraud and she shut up about that and agreed that no one is suggesting that I submit a fraudulent code.
  • (Medical) health insurance lady brings up a secret (to me) clause that says that the patient gets six mental health visits covered under the medical insurance .. before mental health coverage should be invoked … so mental health company should have denied the charge based on the fact that there were fewer than six mental health claims.  The denial from mental health company would then cause the bill to go back to medical company .. where it would be paid.
  • (Mental Health) insurance lady thinks about this a minute and then says it won't work.
  • So I ask for supervisor
  • She puts us on hold (So I'm on hold with medical insurance lady .. and it becomes clear that she is motivated to get this claim back into her company so she can just pay it).
    • Supervisor is in a meeting, please hold a bit longer.
    • Supervisor still in a meeting, but I asked her and she says go ahead … so we will deny the claim based on six visit rule and you should have it back to medical insurance company within a few weeks.
  • I suggest that "should" and "a few weeks" are not reassuring to me and that we really ought to be able to get it back right now ..
    •  how about you two exchange fax numbers and we take care of this now?
  • (Mental Health) insurance lady:
    • I'll put this in the system and request that it be done soon
    • (me:) … uuh .. no .. I'd like you actually DO it instead of plopping it in someone else's lap to take care of later.
    • OK

So it took a bit more than 90 minutes of my time this morning to get paid on a $59 balance from 15 months ago.  Our billing specialist spends her days like this.  We have thousands and thousands of dollars of write-offs every months … for things that we just don't have the energy to follow-up on.  The system is simply broken.  Every company comes up with their own methods of trying to deal tactically with the small problems they see  .. and of course, we respond with our own tactics .. such as hiring billing specialists to argue with theirs.

But what in the world does this have to do with health-care?  Oy … not much.  Will I hesitate before coding for mental health ICD-9 codes?  yep.   Primary care of the future:

• I'm feeling really down, Doctor
• You've got a sore throat today, too, don't you Mrs Jones? (wink wink)  462.0 
• Uhhh .. nope .. I'm depressed.  (311.0)
• Do you have joint pain? (719.0)
• nah .. I'm just really sad .. no physical problems today.

The Primary Care Companion to the journal of clinical pscyhiatry has a good article called Billing for the Evaluation and Treatment of Adult Depression byt the Primary Care Clinician.  (pdf)

It's a good overview of a challenging topic.  It's well documented that primary care physicians are poorly reimbursed.  It's hard to be appropriately reimbursed for our time – which of course is are most valuable commodity.  Funy that I can remove a toenail in 10 minutes and earn several times what I can earn to listen to someone for 45.

Red Sox fans everywhere – I'm sorry about tonight's game – it was my fault.  I'm not one of those crazy sports fans who think that my actions would control the outcome of a game .. but this series has been different.  I can't watch the games.  If I do – the Sox lose.  Last weekend, they won both of those games in Oakland as I was driving to/from Boston on the Mass Pike.   This weekend, Sam and I were at the game on Saturday – and we lost.  Sunday I was banned from the room by my wife – so that I wouldn't watch (and therefore ruin the game).  The won.  Tonight – (I am sooo sorry) I watched one inning with Sam before I sent to the office at about 5:00.  The Yankees got 3 runs in that inning and you know the rest.  I apologize to Red Sox fans everywhere.  I promise not to watch any more Red Sox games!