Kaiser Tightens Rules on Writing Prescriptions

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Los Angeles Times

  Kaiser Permanente said Tuesday that it would abandon a policy of requiring its psychiatrists to prescribe drugs to patients whom they have not personally examined, a practice that drew an investigation by state regulators and a nationwide barrage of criticism that it endangered mental health patients and violated ethics codes.

Under the new policy, Kaiser psychiatrists must now rely on their own examination of patients before writing prescriptions, rather than on the observations of nonmedical psychotherapists, such as social workers and social work interns.

The policy reversal by California’s biggest health maintenance organization came as state regulators and the American Psychiatric Assn. in Washington targeted Kaiser for allegedly violating long-standing medical procedures. State law and the APA’s code of ethics require that physicians conduct an appropriate medical exam of a patient before prescribing drugs.

Kaiser‘s controversial policy came to light in a lawsuit filed last month by a former Kaiser psychiatrist, who was fired after only a few weeks on the job for refusing to prescribe medications for patients whom he did not personally examine.

Apart from filing his suit, Dr. Thomas S. Jensen of San Diego complained to the state Department of Corporations, which regulates managed care. State regulators and APA officials launched separate investigations into the complaint, including allegations that in some cases nonmedical personnel recommended drugs that could have harmed patients.

Jensen’s revelations sparked an avalanche of outrage from patient groups and psychiatrists, who warned that social workers, family therapists and social-work interns are not trained to know the risks, benefits or side effects of powerful psychotropic drugs.

On Tuesday, Dr. Oliver Goldsmith, medical director for Southern California Permanente Medical Group, said the nonprofit HMO decided to review its policy amid the public outcry. “The public attention was a stimulus for us to take another look at this practice,” Goldsmith said. “We felt that this was a street we had to come back from.”

State regulators were looking into several cases in which Kaiser patients were prescribed drugs that were allegedly inappropriate or harmful. Goldsmith, however, said that “we don’t have any reason to believe” Kaiser patients were harmed by the previous policy. He said the practice was confined to Kaiser‘s psychiatric clinics in the San Diego area, which treated 24,000 patients last year.

Jensen–and leaders of several professional groups–reacted with satisfaction when they heard of Kaiser‘s turnabout.

“We’ve actually accomplished something,” Jensen said. “Hot damn!”

Daniel B. Borenstein, the APA’s president-elect and a clinical professor of psychiatry at UCLA, called the change “phenomenal.”

“It goes along with our code of ethics and what we consider to be appropriate practice,” he said.

But Kaiser‘s legal troubles are far from over.

A spokeswoman for the Department of Corporations said the agency was “encouraged” by Kaiser‘s announcement, but she added: “Our investigation will continue.”

Jensen’s attorney, Cliff Palefsky of San Francisco, cautioned that his client would not drop the lawsuit against Kaiser until he sees changes that are “real and complete. We obviously need to wait and understand whether the changes will result in improved quality of care for patients,” Palefsky said.

Kaiser‘s now-abandoned policy refocused public attention on the severe cost-cutting that has dominated managed care since the late 1980s, when companies used a combination of competition and strict controls to slash health-care costs. While such cost-cutting has allowed consumers to receive good care at lower prices, critics say it has also resulted in countless incidents where patients are denied care or receive substandard care.

Kaiser said its policy under which psychiatrists wrote prescriptions on the recommendation of nonmedical personnel allowed physicians to see more patients by eliminating a potentially redundant initial interview. The new policy means that Kaiser may need to beef up its staff of 22 psychiatrists in the San Diego area and make other administrative changes to handle the increased workload, Goldsmith said.

Kaiser held meetings throughout its Southern California psychiatry clinics Tuesday to explain the new policy to staff members.

But some consumer activists questioned Kaiser‘s intentions, saying the HMO reversed its policy merely to avoid a flood of lawsuits.

Among the critics is Jamie Court, whose Santa Monica-based Consumers for Quality Care sued Kaiser last year on behalf of consumers who claimed they were duped by ads that said Kaiser doctors were not influenced by financial concerns.

Court and others have charged that business and administrative goals have cut drastically into the HMO’s medical budget and that many medical protocols interfere with doctors’ medical judgment.

Kaiser realizes that it can’t dodge this bullet, so it takes it,” Court said. “Kaiser still needs to change many of its practices and its advertising for the public trust to be restored.”

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