It would be incredible if insurance would reimburse for the extended time necessary to do ideal psychiatric work including time gathering collateral from family. Unfortunately procedures carry the day for physician payment. Insurance is paying for the services provided, and I think a theoretical liability should exist. Reimburse poorly don’t be surprised doctors have to rush through patients to earn a living.
I find it surprising that a patient who had a longstanding relationship with an outpatient psychiatrist would present to the ER without the outpatient psychiatrist’s knowledge. At the very least, I would expect the family member to have notified the outpatient psychiatrist that their patient was in the hospital. If one of my patient’s becomes suicidal, they typically contact me first and if indicated I refer them to an ER and forward an admission note to the facility with a summary of the patient’s history and medications. It is absolutely appropriate for an inpatient psychiatrist to seek collateral from the patient’s outpatient psychiatrist and to coordinate the discharge with them as well as the family. All of my patients I refer to the ER or Inpatient take a signed release of information to allow both myself and their family/caretakers to receive information from the inpatient providers and not be cut off from all communications until the day before the hospital wants to discharge the patient, when the patient’s insurance runs out or they can no longer get maximum reimbursement. They also give the hospital upon admission a signed release so they automatically get a copy if their inpatient medical records upon discharge. There used to be a cpt code for a “meet and greet” that covered the outpatient psychiatrist visiting their patient in the hospital. And I was reimbursed for this for several cases some years ago. But this issue aside, the opioid/benzo combination problem was compounded by the amount of medication prescribed. I assume the inpatient psychiatrist was aware that the patient had a follow-up appointment with their outpatient psychiatrist in a week and thus should have only prescribed enough or slightly more to cover until that visit. It also seems the family had informed the inpatient psychiatrist that the patient was abusing benzodiazepines, and if so makes his discharging the patient with 90mg of lorazepam malpractice in my book. It’s important though to recognize that the lack of coordination between inpatient and outpatient providers and the use of HIPPA guidelines, which are inappropriately cited as justification to exclude critical family members from communication with the patient family member and their inpatient providers in the care and discharge planning from the point of admission does not benefit and ultimately compromises the patient’s care. Janice E. Cohen, MD San Francisco
As a psychiatrist, I think we tend to worry most about risk of suicide or, in some cases, violence against others due to psychosis or mania. It's a useful reminder to see a medicolegal case history of a suit for falls and hip fracture. Also, IMO, a 90 day Rx for a benzodiazepine, except perhaps in a healthy patient that the doctor has known for years, is a poor standard of care.
When I am dealing with seniors, I tell them, and chart, that most all psychotropic medications are associated with falls and hip fractures in older people. If they are on a benzodiazepine (BZD), I clarify that those are among the worst for fall/ hip fracture risk and that has been known for decades. I rarely prescribe ongoing BZD to anyone, and certainly not in a senior. When I did in patient work, in these cases, I never gave more than 2 weeks of medication.
This is a bullshit case likely settled for a nuisance amount. The amount agreed to was not revealed. There was no departure from the standard of care in relation to fall prevention that is nuts. If the patient had withdrawal seizures the same expert would say that the discharging doctor didn't prevent that. This is typical polypharmacy, in fact not even an exceptional case. I did in-patient psychiatry for twenty years this is precisely how patients are discharged. at my institution and others. And that is what "standard" means.
Just want to make a note that contacting the outpatient psychiatrist while a patient is admitted to a psychiatric unit/facility is not the standard of care. Certainly it could be beneficial in some cases but not always--collateral information is often obtained through family, and at our facility we are provided the patient's past medical/psych history through the EMR, prescription monitoring programs, pharmacy dispense reports and other sources. This renders contacting the outpatient psychiatrist superfluous in most cases - ultimately as an inpatient psychiatrist we are (presumably) well-versed in managing high-risk cases and function in a multidisciplinary team to reduce risk and collaborate care. We provide updates to outpatient psychiatrists who are interested or by patient request (after an ROI is signed) but again, this is not a necessary step in terms of inpatient psychiatric treatment.
Thanks for the insight! I have no doubt that's the standard of care for actual medical practice. Expert witnesses love to make up ridiculous claims about the standard of care that even they themselves don't do. They mistake things that could have been done (or were good ideas in hindsight) with things that any good, reasonable doctor would have done.
It would be incredible if insurance would reimburse for the extended time necessary to do ideal psychiatric work including time gathering collateral from family. Unfortunately procedures carry the day for physician payment. Insurance is paying for the services provided, and I think a theoretical liability should exist. Reimburse poorly don’t be surprised doctors have to rush through patients to earn a living.
I find it surprising that a patient who had a longstanding relationship with an outpatient psychiatrist would present to the ER without the outpatient psychiatrist’s knowledge. At the very least, I would expect the family member to have notified the outpatient psychiatrist that their patient was in the hospital. If one of my patient’s becomes suicidal, they typically contact me first and if indicated I refer them to an ER and forward an admission note to the facility with a summary of the patient’s history and medications. It is absolutely appropriate for an inpatient psychiatrist to seek collateral from the patient’s outpatient psychiatrist and to coordinate the discharge with them as well as the family. All of my patients I refer to the ER or Inpatient take a signed release of information to allow both myself and their family/caretakers to receive information from the inpatient providers and not be cut off from all communications until the day before the hospital wants to discharge the patient, when the patient’s insurance runs out or they can no longer get maximum reimbursement. They also give the hospital upon admission a signed release so they automatically get a copy if their inpatient medical records upon discharge. There used to be a cpt code for a “meet and greet” that covered the outpatient psychiatrist visiting their patient in the hospital. And I was reimbursed for this for several cases some years ago. But this issue aside, the opioid/benzo combination problem was compounded by the amount of medication prescribed. I assume the inpatient psychiatrist was aware that the patient had a follow-up appointment with their outpatient psychiatrist in a week and thus should have only prescribed enough or slightly more to cover until that visit. It also seems the family had informed the inpatient psychiatrist that the patient was abusing benzodiazepines, and if so makes his discharging the patient with 90mg of lorazepam malpractice in my book. It’s important though to recognize that the lack of coordination between inpatient and outpatient providers and the use of HIPPA guidelines, which are inappropriately cited as justification to exclude critical family members from communication with the patient family member and their inpatient providers in the care and discharge planning from the point of admission does not benefit and ultimately compromises the patient’s care. Janice E. Cohen, MD San Francisco
As a psychiatrist, I think we tend to worry most about risk of suicide or, in some cases, violence against others due to psychosis or mania. It's a useful reminder to see a medicolegal case history of a suit for falls and hip fracture. Also, IMO, a 90 day Rx for a benzodiazepine, except perhaps in a healthy patient that the doctor has known for years, is a poor standard of care.
When I am dealing with seniors, I tell them, and chart, that most all psychotropic medications are associated with falls and hip fractures in older people. If they are on a benzodiazepine (BZD), I clarify that those are among the worst for fall/ hip fracture risk and that has been known for decades. I rarely prescribe ongoing BZD to anyone, and certainly not in a senior. When I did in patient work, in these cases, I never gave more than 2 weeks of medication.
This is a bullshit case likely settled for a nuisance amount. The amount agreed to was not revealed. There was no departure from the standard of care in relation to fall prevention that is nuts. If the patient had withdrawal seizures the same expert would say that the discharging doctor didn't prevent that. This is typical polypharmacy, in fact not even an exceptional case. I did in-patient psychiatry for twenty years this is precisely how patients are discharged. at my institution and others. And that is what "standard" means.
Just want to make a note that contacting the outpatient psychiatrist while a patient is admitted to a psychiatric unit/facility is not the standard of care. Certainly it could be beneficial in some cases but not always--collateral information is often obtained through family, and at our facility we are provided the patient's past medical/psych history through the EMR, prescription monitoring programs, pharmacy dispense reports and other sources. This renders contacting the outpatient psychiatrist superfluous in most cases - ultimately as an inpatient psychiatrist we are (presumably) well-versed in managing high-risk cases and function in a multidisciplinary team to reduce risk and collaborate care. We provide updates to outpatient psychiatrists who are interested or by patient request (after an ROI is signed) but again, this is not a necessary step in terms of inpatient psychiatric treatment.
Thanks for the insight! I have no doubt that's the standard of care for actual medical practice. Expert witnesses love to make up ridiculous claims about the standard of care that even they themselves don't do. They mistake things that could have been done (or were good ideas in hindsight) with things that any good, reasonable doctor would have done.