Managed Care's Role in Caring for Suicidal Patients
By James Ellison, M.D., and David Fish
December 1, 2003
Dr. Ellison is president of the Executive Committee for the Massachusetts Psychiatric Society and clinical director of geriatric psychiatry at McLean Hospital in Belmont, Mass.
Mr. Fish is a research assistant for Dr. Ellison.
Second, clinicians must make use of specialty services when necessary, including hospitals, partial hospitals and respite alternatives. While the least restrictive environment for effective care is preferred, there are times when a secure environment such as an inpatient unit remains necessary for ensuring a patient's safety.
Third, clinicians must know and remember that it is their responsibility to appeal the HMO's restrictions on treatment when these intolerably threaten a patient's safety. The legal onus for accurately assessing safety, suicide risk and the likelihood of other untoward outcomes, and planning appropriate care, lies squarely on the physician and not on the managed care company (Hall et al., 1999; Keyes, 2001).When there is a dispute between clinician and insurer, the clinician should not submit to a treatment plan that is unsafe.
In managed care systems that restrict psychiatrist visits to brief pharmacotherapy sessions or cut pharmacy costs by reducing the access barriers to large quantities of potentially toxic pharmaceuticals, clinicians should consider the suggestions listed in the Table.
Fourth, it is important to maintain patient safety and avoid overdosing by prescribing only the amount of medication appropriate. The cost-savings offered by 90-day mail-in prescriptions may be tempting to the patient and their managed care company, but are dangerous when careful monitoring of adherence is necessary. Likewise, changes in medical health and changes in the use of concurrent drugs or prescribed medications may alter the effects or safety of the psychopharmacology, making shorter-term prescriptions a better choice.
Fifth, in larger psychiatric settings, where mental health care is provided by a team, communication and documentation are paramount. Both from a legal and patient health perspective, it is required that team members make contemporaneous notes and also read the notes made by others. Similarly, recording the suicide risk assessment, documentation of family members' concerns and rationale for significant clinical decisions are all advisable. Keyes (2001) reminded clinicians that documentation does not remove the need for oral communication. Caregivers should speak to appropriate team members about serious concerns and document themappropriately.
Managed care has penetrated deeply into our health care system and is likely to remain with us for the foreseeable future. Therefore, we recommend that clinicians remain alert to the risks inherent in managed care while learning to make use of its potential resources. Further studies are needed to truly assess managed care's impact on suicide, and such studies must address the relative advantages and disadvantages presented by managed care in comparison to other health care payment systems.
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