Category Archives: Practice Management

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

Is My Patient Faking?

This article was initially published on MedPageToday, found here.

I remember walking into one of my jails and seeing a patient on the floor of his cell twitching and shaking. “Don’t worry about him,” said the sergeant on duty. “He’s faking it.”
Boy, that spun me up! Nothing will make me more anxious than hearing “he’s faking” or its close cousin, “he’s malingering.” I hate and fear those words. Now, I know that medical personnel, both in my jails and in the emergency departments where I used to work, get upset when they think that they are being deceived or manipulated by a histrionic patient. But charging a patient with “faking it” is almost always a bad and dangerous idea. Continue reading

Gabapentin in the News!

2018 has been a remarkable year for news and research into gabapentin, and the year is not even over yet! That is great news for those of us (myself included) who puzzle over the proper role of gabapentin within correctional medicine. On the one hand, if gabapentin is a useful drug for chronic pain, neuropathy, or any other medical condition, I want to use it properly. On the other hand, gabapentin is a ferociously abused drug within jails and prisons. It is both a sedating and euphoric drug that also can be hallucinogenic at high doses. When it is available within a prison, there is inevitably abuse of gabapentin (like snorting it), diversion of gabapentin (because it has large value within the correctional black market and so can be sold to others), and finally, there is inevitably coercion of weaker inmates by stronger inmates to acquire gabapentin prescriptions and give those prescriptions up to the strong.  Those of us in corrections have seen all of this and worse.

So any news of gabapentin, whether good or bad, can change the balance of this deliberation. If gabapentin is proven to be more effective medically, it may be worth tolerating the abuse. If it is found to be ineffective, there is no reason to introduce this stressor into the system.  With this in mind, here is a sample of the 2018 news on gabapentin. Continue reading

Controlling Health Care Costs: Utilization Management

Consider two people standing outside of a grocery store.

Person one is told: “Here is $200.00 for groceries for one month. You may buy any food you wish—but you may not spend more than this $200.00. So, make your purchases wisely. We are going to watch carefully to make sure that you do not exceed $200.00.”

The second person is told: “There is no limit on how much you spend on groceries in the next month. You may spend as much as you wish! And you may come back as often as you like. There are no limits. In fact, no one is even going to pay attention to what you buy!”

Which person do you think is more likely to walk out of the store with the most expensive cut of steak?
Which person is more likely to pay attention to prices and sales?
Which one do you think is more likely to buy food that they will never eat?

This scenario is very like the difference in health care spending within your average state prison system and the medical community at large. Continue reading

Price Check! Are analogue insulins worth their hefty price?

The analogue insulins were introduced into the United States in the late 1990s and early 2000s. They are called “analogue” insulins because their chemical structure is subtlety different than native human insulin, which gives them different, advantageous properties. Analogue insulins include the short acting insulins Humalog (insulin lispro) and Novolog (insulin aspart) and the long acting insulins Lantus (insulin glargine) and Levemir (insulin detemir).

Since their introduction, the insulin analogues have pretty much taken over the insulin market in the US. That is why I only mentioned human insulins in passing in the JailMedicine post “Insulin Dosing Made Simple.” It is unusual to see patients show up at the jail on any other insulin regimen than analogue insulins, usually Humalog and Lantus. And I have to admit; the analogue insulins are easier to use than human insulins. I like them.

But here is the problem: the analogue insulins have become insanely expensive! When they were first introduced, the price of Humalog and Lantus was around $20.00 per vial of 100 units. That compared to the price of human insulins like Humulin R and NPH of around $5.00 per vial. So the analogues were expensive, but doable. However, since around 2006, analogue insulins have dramatically increased in price—whereas the price for most other diabetic therapies has actually decreased over time. (You can read more about this price increase here)(In the graph above, notice the huge increase in insulin prices since 2006, while every other diabetic therapy price has actually fallen) Continue reading

Inmates cannot go out to find good doctors in the community. Good doctors have to choose to go to them!

I remember the first time someone told me that I was “wasting my talents” by working in a jail. At that time, I had no ready witty rebuttal. I love my job and I especially appreciate working with a patient population that is disadvantaged and underserved. Of course, the idea that incarcerated inmates are worthy recipients of medical care is, well–controversial. Inmates are not as politically correct as other medically disadvantaged populations.

As an example, if you were to tell your family and friends that you were going to work with at a medical clinic for the homeless in an inner city, or to provide medical care in a needy third world country, the reaction probably would be something along the lines of “Good for you! I admire your selflessness and dedication!” Yet when you tell these same people instead that you are going to work in a prison, you are much more likely to get this reaction: “What’re ya, nuts? Why would you waste your talents working with them?” I personally have heard the “you’re wasting your talents” line more than once. Continue reading

Correctional Medicine is a Great Job! Who Knew?

I have a confession to make.  Before I knew anything about Correctional Medicine, I had a bad opinion about it.  I’m not proud of this.  I even turned down my first opportunity to get into Correctional Medicine because of my preconceived prejudice. Thank goodness I got a second opportunity, because Correctional Medicine changed my life! Who knew that Correctional Medicine was such a great job and a great career?

Certainly not my colleagues.  Back when I made the mid-life career change to jail medicine, my physician friends asked me, bewildered, “Why in the world would you want to work in a jail?”  Without knowing anything about it, they had a preconceived notion of Correctional Medicine as being low skill and basically without redeeming features.

What a difference 15 years makes! careersprisondoctor Continue reading

Correctional Medicine Is Different: Our Patients Don’t Go Home!

This post is the final in a series exploring how Correctional Medicine is different than medicine practiced outside of jails and prisons.  The previous three differences were The Principle of Fairness and All Clinical Encounters are Discussed Back in the Dorms and We Can’t Fire Our Patients and They Can’t Fire Us!

The final major difference between correctional medicine and medicine in the outside world is this: Our patients do not go home. We have a captive audience. Literally! Believe it or not, this is a very important medical point.

Back in my previous life as an ER doc, if I asked a patient to come back tomorrow to be rechecked, I knew that few of them would. It was just too much hassle. They had to find a ride back to the ER (especially hard for the homeless or those without cars), they had to endure another prolonged wait in the ER waiting room. And they would be charged big bucks for another ER visit! No wonder so few of my scheduled follow-ups actually returned!

Once I began to practice in a jail clinic, I soon realized that the situation is much different. The patient I see in clinic today will not go home. She will go to her housing dorm down the hall. I know exactly where she will be tomorrow–or in a week. If I want to see her again tomorrow, I can. In fact, I can reliably see her in follow up anytime I want to.

One might think, “So what? What difference can it possibly make on the practice of medicine that our patients do not go home?” The answer is that this fact does indeed have several important consequences for the practice of clinical medicine. I can think of at least four.unknown-1 Continue reading

Correctional Medicine is Different: We Can’t Fire Our Patients—and They Can’t Fire Us!

This post is the third in a series exploring how Correctional Medicine is different than medicine practiced outside of jails and prisons.  The previous two differences were The Principle of Fairness and All Clinical Encounters are Discussed Back in the Dorms.

There is a controversy in pediatrics that I have been following recently. Some pediatricians have been dismissing children from their practice if their parents will not allow them to be vaccinated. This practice has been criticized as punishing innocent children for the actions of their parents but the pediatricians defend it by saying they are just trying to protect their other patients from being exposed to pertussis, measles and other transmittable diseases in the waiting room.

unknown-1This story illustrates an extreme example of something that we all know: that the practice of “firing” patients is commonplace in outside medicine. Many of my jail patients have been dismissed from medical practices, some more than once! Patients can be fired for variety of offenses. Some violate the contracts of their pain clinics. Some are dismissed for simply not following the doctor’s advice—like to get their children vaccinated. Many are no longer welcome when they cannot pay their bills or have lost insurance coverage. (One orthopedist that I know routinely sends a dismissal letter to his patients on their 65th birthday since he refuses to participate in Medicare). Finally, patients can be fired for just being too difficult to deal with. One jail patient in particular I remember screamed drunkenly at his doctor’s secretary to the point that she called the police. He received his official dismissal letter while he was in jail.

Well! Things are different in Correctional Medicine! We can’t fire our patients. Our patients remain our patients no matter what. It doesn’t matter if they violate the terms of a pain contract by, say, diverting medications. It doesn’t matter if they refuse to follow our advice. It doesn’t matter if they are difficult to deal with. Continue reading