Category Archives: Administration

Why Correctional Medicine is often Driven by Lawsuits

Imagine, if you will, a nurse who is assigned to take care of 50 patients on a medical floor—by herself. Clearly, this is an impossible task.  There are just too many patients for one nurse to adequately monitor.  But this nurse gamely does her best.  Now let’s say that there is a bad outcome and an investigation.  Even if the understaffing problem is recognized, it would be easy—and tempting–to scapegoat the nurse, especially if there was no intention of fixing the staffing problem (“We can’t afford to hire more nurses!”)  Instead, the scapegoated nurse would be replaced by a new nurse, who, once again, would be expected to care for 50 patients.

Such were my thoughts when I read this article about the problems with the medical care for inmates in the Illinois prison system (found here):  https://www.chicagotribune.com/news/local/breaking/ct-met-illinois-prison-health-lawsuit-20190103-story.html. The article says that there have been so many problems with medical care in the Illinois prison system that a class action lawsuit has successfully forced Illinois to make sweeping changes to the prison medical system.  What is not mentioned in the article is that similar lawsuits have happened before in other states and will happen again. 

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How to Write an ATP (Alternative Treatment Plan)

Many of us in supervisory positions in correctional medicine have Utilization Management (UM) duties. One common duty is to review requests from primary care practitioners for patient care procedures like a referral or, say, an MRI. We must then decide whether to approve the request or write an Alternative Treatment Plan (ATP). This process is loosely based on a similar practice done in HMOs in free world medicine, but there are important differences. In an HMO, the evaluator is deciding whether the HMO will pay for the procedure. If the requested procedure does not meet HMO criteria, the evaluator will deny the request. The procedure can still be done, but the patient and her physician will have to find an alternative method of paying for it. Also, the HMO evaluator does not offer opinions on whether the procedure is appropriate nor does she offer suggestions as to what could or should be done instead.

Many of us in supervisory positions in correctional medicine have Utilization Management (UM) duties. One common duty is to review requests from primary care practitioners for patient care procedures like a referral or, say, an MRI. We must then decide whether to approve the request or write an Alternative Treatment Plan (ATP). This process is loosely based on a similar practice done in HMOs in free world medicine, but there are important differences. In an HMO, the evaluator is deciding whether the HMO will pay for the procedure. If the requested procedure does not meet HMO criteria, the evaluator will deny the request. The procedure can still be done, but the patient and her physician will have to find an alternative method of paying for it. Also, the HMO evaluator does not offer opinions on whether the procedure is appropriate nor does she offer suggestions as to what could or should be done instead.

Correctional Medicine UM is different. Those of us doing these evaluations are not being asked about payment; we are being asked for permission to do the procedure at all. We cannot simply deny the request like an HMO can. If we do not think the procedure should be done, then we must say what should be done instead: The Alternative Treatment Plan.

When done poorly, the ATP can irritate the primary care practitioner and even create an adversarial relationship between the practitioner at the site and the UM evaluator. When done well, the ATP is a written conversation between two equal colleagues and the ATP process can actually improve patient care.

Doing it wrong

Like any other bit of writing, it is important at the outset to define who your audience is. The ATP should be written with three potential readers in mind. The first is the site practitioner who made the initial request. A bad ATP will leave the PCP feeling underappreciated, threatened and disrespected: “I don’t trust you and you are stupid.” A good ATP will leave the PCP feeling like you are on the same team and that you have their back: “You’re doing great! Let me help you.”

The second potential reader of the ATP is The Adversary, like a plaintiff’s lawyer or an advocacy group. A bad ATP will indicate that you are denying the patient reasonable and necessary medical services. A good ATP will show that nothing was denied and will not imply that any medical service is off limits.

ATPs are also read by nurses, who have to transcribe and record the ATP in the official record. A good ATP will make their life easier. A bad ATP can result in many hours of needless, morale crushing busy work.

In my experience, it does not take much more time to write a good ATP instead of a crappy one.  Most UM evaluators, however, have never been taught how to write and ATP.  Here is how I write mine:

Step one: Restate what is being requested.

The first sentence of the ATP should briefly summarize the case and re-state what is being requested.

  • 56 yo male s/p colonoscopy done for guaiac positive stool. Request is for a routine post procedure FU with the gastroenterologist.
  • 63 yo male with reported gross hematuria.  Request is for CT of the abdomen.

Step two. Support your ATP.

The next section of the ATP contains the evidence that supports your ATP. This evidence can be pertinent positives, like x-rays, labs, previous visits. This evidence can also be pertinent negatives, like incomplete exams or missing data. Finally, this paragraph can also include pertinent research that supports your ATP, such as a quote from Uptodate, RubiconMD or InterQual.

  • The colonoscopy was negative except for a single sigmoid polyp. The pathology report on the sigmoid polyp is not attached to the report.
  • There is little clinical information accompanying the request.  I do not know if the patient has other medical problems, findings on physical exam, what medications he is one or what labs have been done.  Review of published treatment algorithms for the diagnostic work up of hematuria (Essential Evidence, Uptodate) show that CT is not the first diagnostic procedure that should be considered in most cases of hematuria.

Step 3. The ATP should defer the request; not deny it.

It is important to never (or rarely) use the word “denied.” Instead, you should restate what was requested and then say it is “deferred “pending whatever you want done instead, such as “Pending receipt of missing information,” “Pending complete evaluation of the patient at the site,” or “Pending case evaluation in a case review conference”

  • Routine post-procedure FU with GI is deferred, pending complete evaluation of the patient and colonoscopy findings at the site.
  • Abdominal CT is deferred pending complete evaluation of the patient at the scene.

Step four. Tell the Primary Care Practitioner what you want them to do instead.

The next sentence contains instructions to the site practitioner.  This is the “ATP” and should be labelled as such.  I also always date the ATP.

  • 3/11/2019 ATP: The site practitioner should obtain the pathology report on the sigmoid polyps and call me to discuss the case. The timing of follow colonoscopy will depend on the biopsy results.
  • 3/11/2019 ATP: The primary care practitioner should do a complete physical examination, appropriate labs and then discuss the case with me as to the next appropriate diagnostic procedure (ultrasound, cystography, etc).

Step five. State that whatever was requested can be reconsidered later.

I always add this last sentence as well, to reaffirm that I am not denying any medical care. “The request from the first paragraph” can be considered thereafter, if clinically appropriate or anytime if medically necessary.

  • Off-site GI visit can be considered thereafter, as clinically indicated–or at any time if appropriate.
  • CT can be considered thereafter, if clinically appropriate, or anytime if medically necessary.

Step six: Contact the PCP to let her know that her request was ATP’d.

I don’t think that PCPs should find out from a UM nurse that their request was ATP’d. They will feel much better about the process if you contact them. This also opens a method of communicating about the case if they have more questions. This can be accomplished with a simple email:

  • Hi Dr. X! Before we send this patient off-site to see the gastroenterologist, we need the biopsy report. If the adenoma is low risk, you can deliver the good news to the patient and tell him when his next colonoscopy will be scheduled. You’ll be seeing him in chronic care clinic in the meantime.
  • Hi Dr. Y!  I am attaching an algorithm for work up of hematuria.  As you can see, there are several things that should be done before we consider a CT.  Will you please call me to discuss this case?

Putting it all together, here are the full ATPs:

  • 56 yo male s/p colonoscopy done for guaiac positive stool. Request is for a routine post procedure FU with the gastroenterologist. The colonoscopy was negative except for a single sigmoid polyp. The pathology report on the sigmoid polyp is not attached to the report. 3/11/2019 ATP: Routine post-procedure FU with GI is deferred, pending complete evaluation of the patient and colonoscopy findings at the site. The site practitioner should obtain the pathology report on the sigmoid polyps and call me to discuss the case. The timing of follow colonoscopy will depend on the biopsy results. Off-site GI visit can be considered thereafter, as clinically indicated–or at any time if appropriate. Email to PCP: Hi Dr. X! Before we send this patient off-site to see the gastroenterologist, we need the biopsy report. If the adenoma is low risk, you can deliver the good news to the patient and tell him when his next colonoscopy will be scheduled. You’ll be seeing him in chronic care clinic in the meantime.
  • 63 yo male with reported gross hematuria.  Request is for CT of the abdomen. There is little clinical information accompanying the request.  I do not know if the patient has other medical problems, findings on physical exam, what medications he is one or what labs have been done.  Review of published treatment algorithms for the diagnostic work up of hematuria (Essential Evidence, Uptodate) show that CT is not the first diagnostic procedure that should be considered in almost all cases of hematuria. 3/11/2019 ATP: Abdominal CT is deferred pending complete evaluation of the patient at the scene.  The primary care practitioner should do a complete physical examination, appropriate labs and then discuss the case with me as to the next appropriate diagnostic procedure (ultrasound, cystography, etc).  CT can be considered thereafter, if clinically appropriate, or anytime if medically necessary. Email to PCP: Hi Dr. Y!  I am attaching an algorithm for work up of hematuria.  As you can see, there are several things that should be done before we consider a CT.  Will you please call me to discuss this case?

Two more examples (minus email):

53 yo s/p treatment for tongue cancer in remission. Request is for routine FU with ENT at six months from last visit.
The patient has finished all of his radiation sessions. ENT note from 7/17 states that the patient is in remission and that the six-month FU visit is “prn.” The consult request notes no new symptoms.
3/11/2019 ATP: ENT consultation deferred. Per last visit with ENT, further visits are to be “prn.” The site PCP should evaluate the patient at 6 months from the last visit and again at one year from the last visit. Off-site visit with ENT can be considered thereafter, as needed–or anytime if clinically necessary.

62 yo who had a liver ultrasound as part of Hepatitis C staging. The ultrasound showed a hypoechogenic polyp or cyst at the neck of the gall bladder. The radiologist says “A CT may be of value.” There is no report that the patient is symptomatic. I submitted the case to a RubiconMD radiologist, who thinks this is an incidental finding and repeat ultrasound in 6 months is a better methodology to follow this incidental finding.
3/11/2019 ATP: Abdominal CT is deferred. Per RubiconMD radiologist’s recommendation, the site PCP should order a follow up ultrasound at ~6 months. CT may be considered thereafter as clinically appropriate (or anytime if necessary).

As always, what I have written here is my opinion based on my training, experience and research.  I could be wrong! If you disagree, please say why in comments.

A previous version of this article was published in CorrDocs, the Journal of the American College of Correctional Physicians

Medical plan

Utilization Management is Different in Corrections

This is an important fact that I have learned from many years working in prisons and jails: Most correctional practitioners do not understand how Utilization Management in a prison system works. They misunderstand what the goal of the UM process is. They misunderstand the process of submitting requests. And they misunderstand how decisions are made. It took me a full three years of working in a prison system before I wrapped my head around how UM was supposed to function. This is because UM within a correctional system is fundamentally different than UM in the outside world and also new incoming correctional practitioners are not taught how prison Utilization Management works or how to make UM requests properly.

To show how a prison is different than Utilization Management in a typical Health Maintenance Organization (HMO) in the outside world, let’s say that I am a primary care practitioner in the community who wants to order an MRI on one of my patients. As we all know from long experience, I can’t just order the MRI. I have to get it pre-authorized. To do that, I have to submit paperwork to the patient’s insurance company explaining why I want to do the procedure. Someone will review my request, but I will have no idea who this person is or what their qualifications are. The reviewer could be a physician, or it could be a nurse referring to UM guidelines.  I just don’t know and never will. Whoever that person is, they will either approve payment for the procedure or deny it.

Notice several important things about this interaction: Continue reading

Grievance Responses PLUS Sample Grievance Guideline

Benjamin Franklin once famously quipped “nothing is certain but death and taxes.” However, Franklin did not work in a jail, otherwise he would have said: “Nothing is certain except death, taxes and grievances.”

On the outside, patients do not write grievances—they vote with their feet. If they dislike the medical care they are receiving, they will just go to a different doctor. In a jail, they cannot do this. We have a grievance system in Correctional Medicine because our patients cannot fire us (and we cannot fire them–discussed previously here). If jail patients are unhappy with their medical care, their only recourse is to write a grievance.

Grievances are not necessarily bad things. A medical grievance is sometimes the way by which jail patients alert us to significant problems that we may have not known about or mistakes that we made. I myself have had my butt saved in this manner—more than once! Many grievances are simply about communication errors. We have not yet adequately explained a medical decision to the patient.

Yet jail medical personnel often have a bad attitude about grievances. This is unfortunate, because medical grievances are an important—even essential—part of the jail medical system. I believe that the most important reason for the bad attitude is that people have not been taught how to write a proper grievance response. That, then is the topic of today’s JailMedicine post. Continue reading