Not long ago I had a conversation with a psychiatrist. He told me about a diagnostic dilemma he’d run up against at work.
It’s not that he didn’t know how to create an accurate diagnostic label for a patient according to the book. The DSM works a bit like a Chinese menu. One from column A and two from column B for at least two weeks equals diagnosis C. He’s quite good at this.
In a way, being accurate and by the book is one part of the problem he’s run into.
His diagnostic dilemma doesn’t come from problems with the criteria being used to make the diagnoses or with psychiatric diagnoses per se. Rather, his diagnostic dilemma arises from the purposes for which these labels are used.
Specific types of psychiatric diagnoses are used as magic keys that unlock funding gates for psychiatric services, medical insurance and some types of government support payments.
If the psychiatrist doesn’t provide a “payable” type of psychiatric diagnosis from a specific list, the provider organization he works for will not get paid. And provider organizations can’t afford to give away free patient care. When the psychiatrist doesn’t create a “payable” psychiatric diagnosis, this blocks the patient’s access to mental health services. Not making one of these “payable” diagnoses can also block the patient’s access to insurance for medical care and some kinds of public assistance money.
This psychiatrist was unwilling to use one of these “payable” labels for a certain person. He said it just wasn’t accurate based on his evaluation. He’d been criticized by co-workers on the grounds that he had denied the patient access to needed care.
A tangled web of ethical, legal and human issues arise within a system that requires a specific coded psychiatric diagnosis before a poor person can receive counseling, access to medical care and money to live on.
And it’s fraud if the doctor creates a false diagnosis for payment or benefit purposes.
So the psychiatrist is caught between the legal and ethical issues of fraud on the one hand and a desire to help his patient access resources on the other. This is a rock and a hard place for everyone concerned.
But there’s more to this conundrum.
Some of these unfunded patients arrive at the psychiatrist’s office through legal mandates to treatment. A judge can order a person to get into mental health treatment. The consequences of disobeying this legal mandate can include loss of children and incarceration.
This legal situation leaves both the psychiatrist and the unfunded patient with the need to produce a “payable” diagnosis so that the patient can access money to pay for the court-mandated treatment. When a judge makes an unfunded treatment mandate as part of her judgment, she pressures the doctor to make a “payable” psychiatric diagnosis.
The American Psychiatric Association’s professional practice guidelines recommend daily drugging for many “payable” psychiatric diagnoses. Once this “payable” diagnosis is in place, drugs generally follow.
If the psychiatrist decides against giving the diagnosis-driven drugs spelled out by the A.P.A. guidelines, he places himself at risk. No matter what goes wrong in that patient’s life, the doctor can be held liable for not providing drugs according to the “practice guidelines”. Neither the doctor’s employer nor his professional liability insurance will stand behind him if he chooses his own judgment over “practice guidelines”.
The doctor who makes a correct diagnosis but does not label a person with a “payable” psychiatric diagnosis can be denying his patient money to live on, counseling and access to medical care. Not labeling a patient who’s been mandated to treatment by a judge can result in the patient going to prison.
If the doctor stretches the truth out of sympathy and provides an inaccurate but payable diagnosis so that his patient can have access to medical care and money to live on, he is committing fraud that can mean heavy fines and incarceration for himself.
It seems there is no right thing for the doctor to do. Every choice he can make is wrong. He can commit fraud to get resources for a poor person and risk his self or remain diagnostically correct and leave the patient without money and care.
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Thanks or reading, thinking and writing.
Alice Keys MD