TALES FROM THE CLINIC

-Series Editor Nidal Moukaddam, MD, PhD

In this installment of Tales From the Clinic: The Art of Psychiatry, we meet a distraught mother who is worried about her daughter’s health. Patient care is at the nexus of personal experience and everyday payor contractual arrangements with companies and facilities that provide the care. Many factors affect the outcome: care team composition, their interface with family, care team’s clinical knowledge, understanding of shared decision making, expertise and understanding of scope of practice limitations and recognition of these limitations. Ideal care involves promptly reaching out for consultation and supervision. Legislative and legal realities at the state and federal levels (pertaining to payer “out of network” selections, state versus federal regulations, etc) are difficult to navigate even for seasoned practitioners, and are beyond the knowledge of most families. The experience of illness is deeply personal and can be painful, but few members of the public are equipped with the knowledge to understand the complexities of our health care system. The case, which is fictional, involved Aletheia Phoenix, MD, who is writing under a pseudonym given recent developments in health care.

Case Study

“Ms Sarah” is a 17-year-old female status post carcinoid tumor removal. She has a history of autism spectrum disorder, with baseline language production consisting of 2- to 3-word sentences. She receives special education in school and sees a speech and occupational therapist. Changes in her routine or unwanted sensory input, such as loud noises and flashing lights, can trigger agitation consisting of punching, spitting, and biting. She is a picky eater. Over the years, Ms Sarah has had exacerbations and remissions of her behavioral symptoms and had mostly stabilized on a combination of sertraline and lithium, which was managed by the university child psychiatry clinic, staffed by psychiatry faculty and trainee physicians. Three years ago, Ms Sarah started having difficulty breathing, with high fevers, wheezing, and bloody cough with diarrhea, which led to a hospital admission. She was first treated empirically for presumptive pneumonia and then empirically for anthrax based on her history of spending time in the countryside with her grandmother’s cattle. However, bronchoscopy diagnosed a carcinoid tumor. Tumor resection led to symptom resolution. Her psychiatric medications were tapered postsurgery due to concerns for precipitation of serotonin syndrome in the rare event of a tumor recurrence.

Ms Sarah’s mother also reports that she was told by the doctors to exercise caution when continuing any depression and anxiety medication, and to consult a child psychiatrist for her treatment. Meanwhile, Ms Sarah continued to have severe anxiety and agitation. Following discharge from the hospital, Ms Sarah was admitted to an inpatient psychiatric unit for 10 days and then discharged home on valproic acid and risperidone, which alleviated some of her aggression and anxiety symptoms. She began to eat more and gained a significant amount of weight; however, her mood improved. She received monthly follow-up visits from the hospital’s clinic.

However, about a year ago, Ms Sarah’s brother took the family car for a joyride and crashed it. Due to the absence of proper transportation and limited mobility, Ms Sarah had to receive psychiatric follow-up care from a local clinic. Her mother lamented that they live in a very rural part of a mountainous state where a nurse runs the clinic with another psychiatry provider who is only available virtually. Her mother reported that there are no doctors at this clinic, and she was worried about Ms Sarah’s significant weight gain and the possibility of diabetes. The provider advised her mother to consider stopping the risperidone, to which she attributed the weight gain. This led to Ms Sarah getting increasingly perturbed by noises and lights, to the point she refused to leave the house. She became pickier with food again. Within another couple of weeks, her aggressiveness returned, resulting in an emergency department (ED) visit. With no psychiatric inpatient availability, she was instead admitted to a local residential facility.

When Ms Sarah was newly admitted, her mother briefly heard from a provider that Ms Sarah was on the “wrong” medications. This provider substituted lithium for valproate due to weight gain and restarted risperidone. Also, due to anxiety, isolation, and poor appetite, the facility initiated sertraline; Ms Sarah previously responded well to it. Her mother told the provider about the history that led to the hospital admission and subsequent surgery. The provider requested her mother sign a release and told her that they will “look into it” once the records arrive at their facility. The records never arrived and there was no electronic health record to facilitate history obtention.

The next few weeks were difficult. The mother managed to arrange a ride once a week with a friend to visit Ms Sarah. Based on these visits, the mother believed Ms Sarah’s condition was deteriorating, manifested by continued impulsivity, agitation, and dysphoria. She also noted some galactorrhea. The mother received occasional communication from the prescribing clinician and a weekly update from her daughter’s individual therapist, although no meaningful therapy could be conducted given poor verbal status.

After 12 weeks of treatment, Ms Sarah’s mother received a call from the residential facility indicating her daughter was not doing well: Ms Sarah had flipped a table, punched a hole in the wall, and attempted to bite staff. Her mother traveled to the facility and asked to speak to the treating doctor but was informed that the provider comes only once a week. The mother then learned the once-a-week clinician was a psychiatric nurse practitioner with a doctorate of nursing practice assigned for medication management weekly. If other problems arise, the mother is told certified psychiatric technicians call the registered nurse, who then calls the treatment administrative director, who decides if the lead clinician needs to be called.

The day when Ms Sarah had escalated was an outlier; despite efforts, she was referred to the ED with hopes of an inpatient hospitalization. The hospital treatment team elected to not modify medications, due to the history of serotonin syndrome documented during the previous hospitalization. Dosages of lithium (150 mg oral, twice a day), risperidone (2 mg oral, twice a day), and sertraline (50 mg oral, once in the morning) remained unchanged.

Meanwhile, the mother was notified by the facility about payor related issues. “The family’s payor authorized multiple durations of requested stay due to Ms Sarah exhibiting continued escalation. At the most recent review, the stay was denied with a recommendation for higher level of care,” the clinical director told her. However, the director said the facility was attempting to appeal this decision “to keep Ms Sarah at the lower level of care,” ie, the current residential level of care, even though Ms Sarah met medical necessity for an inpatient level of care.

To add to the confusion, the insurer’s representative clarified that the acute hospital admission would be covered by insurance, but ongoing treatment at the residential facility would be at the previously agreed upon out of network cost. It was not long before confusion was replaced by frustration, as Ms Sarah’s mother felt the facility had not made adequate and skilled targeted treatment efforts in a systematic manner. She felt this poor care resulted in additional suffering for her daughter due to symptom burden as well as higher costs due to the longer duration of stay. A myriad of questions lingered (Table 1).

Table 1. Questions From Case Example

Discussion

Most health care in the US is reimbursed and administered via insurance. The Government Accountability Office and the census estimate that 92% (305.2 million individuals) had health insurance for some or all the year in 2023. In the same year, private health insurance coverage continued to be more prevalent than public coverage, at 65.4% and 36.3%, respectively.¹

The inherent business nature of insurance (ie, costs are closely examined) has resulted in approving levels of care clinical determinations based upon medical necessity criteria. In turn, this approach brings with it a high level of streamlining, which can be confusing for families. Since the attributes, goals, and missions of health care (Table 2) theoretically are aligned for clinicians and insurance companies, why do patients not enjoy ideal care in real life?

Table 2. Insurance Goals of Health Care

The insurance company perspective. Insurance companies utilize medical necessity criteria, one of which is the Milliman Care Guidelines (MCG) guidelines. The MCG guidelines were developed based on published medical evidence, clinical expertise, and objective, standardized analysis of various databases and are reviewed annually.³ The behavioral health care section provides guidelines for the treatment of psychiatric disorders such as major depressive disorder, anxiety disorders, schizophrenia, and eating disorders and details the appropriateness of specific psychological, behavioral, and pharmacologic therapies. Indications are presented for 5 different levels of care (ie, inpatient care, residential care, partial hospital program, intensive outpatient program, and outpatient care).

Specifically, MCG has stated⁴:

One of the principal uses of database information is to verify the reasonability of the inpatient level of care via parameters such as Goal Length of Stay (GLOS). When cited in a guideline, the database analysis is reported as a percentage of patients in the United States who are discharged from an inpatient admission at or before the GLOS. The database is not restricted by payer (eg, commercial, Medicare, and Medicaid are represented) and includes patients of all ages (except where noted, for example in child or adolescent guidelines).

Thus, clinicians are expected to (1) learn about the appropriateness of each level of care for patients like Ms Sarah; (2) gauge an appropriate length of stay; (3) know when it is appropriate to move to another level; (4) be transparent with family members and frequently update family members, as this is beyond the scope of health literacy for families; and (5) understand relevant clinical rationale, such as MCG rationale, that outline recovery courses.

Recovery milestones. Recovery milestones are used to determine if ongoing care, interventions, and documentation indicate that continued care at the current level is warranted. Absence of achievement of milestones should prompt questions about the expected timing of unmet milestones and appropriateness of continuing the level of care or moving to a more appropriate level of care. Not only do clinicians need to understand these milestones, but they are also expected to transmit this information to patients and families in real-time and facilitate their understanding. For example, in this case study, Ms Sarah’s family should have learned about the appropriateness of each level of care for their daughter and about appropriate length of treatment.

When/how things go wrong. Care that is complex and results in less than ideal outcomes is stressful and bound to result in disagreement and blame shifting. In some scenarios when care goes wrong, treating physicians may feel insurance companies are presumptuous in dictating care. Worse, families and patients are caught in the middle of complex criteria.

Role assignments are intrinsic barriers when looking at large care systems. Specifically, there is a host/flurry of titles, from clinical directors to case managers and other nonphysicians, all of whom contribute to patient trajectories. As the physician’s role has decreased, patient care management may be delegated to individuals with less pertinent training; this may be more pervasive in the treatment setting with less acute care. Similarly, fragmentation of care has been observed as a result of an amalgam of various decision-makers. This may be especially evident for patients who cannot advocate for themselves. An effort to reduce roles to prescriber, treatment director, and clinical director, essentially leads to an absence of unified comprehensive patient care.

In the case study, the worry of a history of serotonin syndrome prevented the team from changing medications despite lack of efficacy and an adverse effect of Care fragmentation here is reflected in 2 main failures of treatment adjustment: (1) frequency of medication management visits was not modified to meet levels of acuity, and (2) level of complexity (residential) precluded comprehensive management. Thus, things turned for the worse for the patient due to lack of appropriate communication among the care team, as well as the lack of available experts for the complications that arose.

The case leaves us with many questions, all of which can impact patient care.

• What are adequate qualifications, experience, and expertise necessary to handle complex cases such as Ms Sarah’s? Who makes this determination?
• What safeguards are/should be in place to obtain more specialized expertise? Who decides when this is needed?

And, more pertinent to this case:

• Did the provider review the previous records? If they did, was there an effort made to reach out to the treatment team that cared for the patient when they were critically ill with serotonin syndrome?
• Did the provider immediately and subsequently reach out to the mother about available evidence-based treatment options? Why did they not involve the mother in shared decision making?
• Given the complexity and acuity of the clinical presentation, why were there not more frequent med-check visits and monitoring?
• Why did the clinical director (who has no medical training) determine the frequency in which the provider can see the patient? Why did the provider not have the liberty to see the patient when clinically indicated?
• Who supervises treatment, which at this point appears to have become stagnant and does not meet the patient’s needs?
• Who in the care team should have made those decisions? Although, the aforesaid team model boasts of a purported team-based model, there is significant evidence of fragmentation of care.

Concluding Thoughts

This case highlights the real-life complexity of medical and psychiatric comorbidities and the need for a tight, focused, goal-driven approach and management. Truncated and incomplete clinical approaches due to insurance or facility limitations as well as the lack of available expert consultations can be detrimental to patients. As a country, we can—and need to—do the best for our patients and their families. We strongly recommend a call to action for patients, families, and all health care team members to be active partners in feedback and system enhancements.

Dr Moukaddam is a professor of psychiatry at Baylor College of Medicine, Department of Psychiatry, and the Director of Outpatient Psychiatry at Harris Health System. She also serves on the Psychiatric Times Editorial Board. Dr Shah is executive vice chair and Barbara & Corbin Robertson Jr. Endowed Chair in Psychiatry at Baylor College of Medicine, Department of Psychiatry. Dr Phoenix is an anonymous clinician with wide experience in private and insurance sectors.

References

1. Keisler-Starkey K, Bunch LN. Health insurance coverage in the United States: 2023. United States Census Bureau. September 2024. Accessed March 14, 2025. https://www2.census.gov/library/publications/2024/demo/p60-284.pdf

2. Blumenthal D, Gumas ED, Shah A, et al. Mirror, mirror 2024: a portrait of the failing U.S. health system. September 19, 2024. Accessed March 14, 2025. https://www.commonwealthfund.org/publications/fund-reports/2024/sep/mirror-mirror-2024

3. MCG Behavioral Health Care Guidelines. Accessed March 14, 2025. https://www.mcg.com/care-guidelines/behavioral-healthcare/

4. Premier PINC AI™ Healthcare Database: Data That Informs and Performs. December 2024. Accessed March 14, 2025. https://offers.premierinc.com/rs/381-NBB-525/images/PINC_AI_Healthcare_Data_White_Paper.pdf