Tag Archives: prisons

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 a Concrete Cell Really the Best We Have To Offer Our Mentally Ill?

Consider the case of a 60-year-old patient I will call “Library Man.” While at the public library, Library Man took off most of his clothes and was talking loudly to no one in particular. The police were called, of course. He was charged with disturbing the peace and brought to my jail.

Jails basically have three types of housing areas. First are dormitory-style rooms with 60-100 residents. Library Man cannot be housed there—the young aggressive inmates would prey on him. Second are smaller cells that hold two to four inmates. The problem with these cells is that even if the jail could guarantee gentle cell mates, it would be hard to monitor Library Man in such cells. Such cells tend to be in out-of-the-way places and have small windows on the doors. The only place that Library Man can be reasonably housed in most jails is “Special Housing,” which refers in this case to a single-man isolation cell with lots of plexiglass to allow easy observation. Such rooms are designed to have nothing that someone could use to harm themselves, so they are made entirely of concrete and steel—even the bed. This is where Library man ends up—basically in a large concrete box.

Unfortunately, this is not a good place for Library Man to be. You may have guessed that Library Man is a homeless schizophrenic who had gone off of his meds. He is harmless–certainly not a danger to himself or to others. In his psychotic state, he does not understand why he was arrested and jailed. Library Man would benefit from familiar surroundings and normal social interaction with people. He will get neither of these in the alien and sterile environment of his concrete isolation cell. 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

Guest Post: A Prescription for Dog Food

Today’s Post was written by Rebecca Lubelzyk MD.  Rebecca works in the Massachusetts prison system. She is a past president of the American College of Correctional Physicians and the editor of CorrDocs, the official publication of ACCP.  This article was originally published in CorrDocs.

I’m on a medical school listserve that publishes writings and academic accomplishments of faculty and students. One week, a mindfulness moment was added to address the stress that physicians feel. The well-intentioned addition brought forth a fairly online virulent discussion about the non-medicine stress that disgruntled physicians feel every day, and how a “mindful moment” will do little to change the extreme performance demands generally imposed upon our profession.

I followed the discussion peripherally but with interest. It was clear all the contributors were dedicated professionals who loved their patients and providing care to them and their families. However, the bitterness towards the insurance/compensation/financial system was prevalent.

How bad it was “out there” became even more apparent when I had a prospective physician shadow me in clinic for a day. I explained how there can be several benefits to correctional medicine (your “no show” rates are essentially nil, patients have their blood pressures and blood sugars checked by a nurse, diets, commissary purchases can be reviewed in detail, etc.) I expressly noted the unique challenges, including the requests for non-medical items or privileges as well as the negative attitudes one encounters when the patient doesn’t want to hear the word “no”.

The physician candidate surprised me, stating that it was the same on the outside. Continue reading

Top Five Articles from 2018

2018 was a great year for JailMedicine! Noteworthy events from the year include:

I introduced a new feature–Sample Guidelines–which turned out to be very popular. I intend to add many more sample guidelines this year. Please let me know what guidelines you would like to see!

I began a new blog on MedPage Today entitled “Doing Time: Healthcare Behind Bars” (found here) that introduces our world of Correctional Medicine to outside medical professionals who have no idea what we do. This has also been well read.

Readership increased substantially in 2018. This may be because I published more articles . . . Thank you to everyone who read JailMedicine this year!

Without further ado, these are the five most read articles from 2018:

Abscess Incision and Drainage, a Photographic Tutorial

I was given the opportunity to create a tutorial of the classic method of lancing an abscess when a friend of mine came to my office with a great cutaneous abscess on his back.  This has been, by far, the most read JailMedicine article of all time.

Removing Microdermal Implants, A Photographic Tutorial

Microdermal implants are so common as to be ubiquitous.  Almost all of th jewels can be unscrewed from the base, which is my preferred way to deal with them in a jail setting.  However, occasionally, patients want to have the implant removed entirely. It is not hard, but many practitioners have never done it and so do not know how.

A Better Way to Drain Abscesses: The Berlin Technique

I have a confession to make.  I no longer (usually) incise and drain abscesses in the manner that I taught on the photographic tutorial above.  My dermatologist friend and colleague, Neelie Berlin, showed me this nifty technique that uses a 4mm punch biopsy tool  It is quicker, easier and just as effective for the majority of uncomplicated skin abscesses you will see in your clinics.  You just have to order the punch biopsy tool!

What’s the most cost-effective way to treat scabies? The answer might surprise you

Scabies is so common in jails that every jail medical professional should know how to recognize this itchy little pest. It is not too hard as this post points out.  Also, It turns out that treating scabies with oral ivermectin is less expensive and easier than using topical permethrin cream.

Medications at High Risk for Diversion and Abuse In Correctional Facilities

Many seemingly benign medications are commonly diverted and abused in correctional facilities.  The risk of abuse for some of them so overwhelms any potential benefits of these drugs that I argue that they should rarely be used in jails and prisons.

What was your favorite post from JailMedicine?  What should I address in future articles? Please comment!

Sample Guideline: Bottom Bunk Requests

This clinical guideline is intended to be used as a template to help clinicians and administrators create their own policies. This sample guideline must be modified to make it applicable to each unique correctional facility. This guideline is not intended to apply to all patients. Practitioners should use their clinical judgement for individual patients.

Introduction. Occasionally, inmates who have been assigned the top bunk of a bunk bed state that they have a medical condition that requires them to be given the bottom bunk instead. Since medical providers must be fair and consistent, it is important to differentiate medical need for a low bunk from requests made for non-medical reasons such as a desire for convenience or as a sign of increased status.

Medical need. Medical need for a low bunk generally falls into one of two categories: Patients who are unable to safely climb onto the top bunk because of physical limitations and patients who have a medical condition that might lead them to fall off of the top bunk and injure themselves.

Patients who are unable to safely climb onto the top bunk because of physical limitations include:

  • Obesity (BMI >30)
  • Advanced age and/or infirmity
  • Late term pregnancy.
  • Permanent physical disabilities, such as amputations, paralysis, or previous strokes.
  • Temporary physical disabilities such as a broken bone or recent surgery.

Patients who have a medical condition that might lead them to fall off of the top bunk include:

  • Seizure disorders which are current and ongoing.
  • Conditions causing vertigo or dizziness, such as Meniere’s disease.
  • Conditions which impair coordination such as cerebral palsy.

Chronic pain syndromes independent of other conditions such as those listed above generally do not constitute a medical need for a bottom bunk assignment.

Patients who have been successfully using a top bunk generally do not have a medical need for a bottom bunk reassignment unless their medical condition has acutely changed, such as with a traumatic injury. Example. A patient has been using a top bunk for three weeks. Now he comes to medical stating that there are several bottom bunks available in his pod. He would like medical to approve a bunk reassignment for him because of an old leg injury. The fact that he has been using a top bunk for three weeks indicates that this patient does not have a legitimate medical need for a bottom bunk.

Nursing Personnel may address routine patient requests for low bed assignments based on this guideline. If nursing personnel are unsure or have questions, they may refer the patient to a medical practitioner.

Documentation. Security personnel assign bunks, not medical personnel. Medical personnel are being asked if a patient has a medical need for a low bunk assignment. Therefore, medical personnel should document the answer to this question only.

Incorrect: “Bottom bunk request is not approved.” Correct: “This patient does not have a medical need for a bottom bunk assignment.”
Incorrect: “Bottom bunk is approved for medical reasons.” (Security staff may elect to place the patient on a single bed, a cot, or a floor “boat” instead of a bottom bunk.)
Correct: “This patient should not be assigned a top bunk for medical reasons.”

If a patient does have a legitimate medical need for a low bunk assignment, consideration should also be paid to the patient’s other housing needs. For example, a low bunk may not actually meet the patient’s needs; the patient may need a hospital bed. Patients who have a medical need for a low bunk assignment may need to be restricted to a bottom tier so that they will not have to climb stairs. Patients who are inmate workers may need work restrictions. If the medical need for a low bunk assignment is temporary (such as a broken arm), the bottom bunk memo should have a time limit.

Sample guidelines can be found under the “Guidelines” tab (above) as they are published. I view these sample guidelines as a group effort! If you have a suggestion, critique or simply a better way to phrase some concept, say so in comments!

Opioid Withdrawal Not Deadly? Wrong!

One thing I always tell practitioners who are beginning a jail medical practice: you’re going to see a lot of withdrawal cases — study up! In particular, since the opioid epidemic hit, the number of patients I’ve seen in my jails withdrawing from heroin and other opioids of all stripes has skyrocketed. I’ve seen enough patients withdrawing from opioids that I think I am reasonably knowledgeable on the topic. Because of this, I was quite surprised when I ran across this sentence in a recent edition of The Medical Letter:

“Opioid withdrawal is not life-threatening.” — The Medical Letter

The problem is that although this sentence seems quite self-assured, it is flat out wrong. In fact, it is not just wrong; it is also dangerous. People do die from opioid withdrawal. I know of several such cases from my work with jails. Opioid withdrawal needs to be recognized as a potentially life-threatening condition, just like alcohol withdrawal and benzodiazepine withdrawal. Continue reading

Sample Food Allergy Guideline

Today’s post is the second in a series of sample clinical guidelines.  All of these sample guidelines will be placed under the “Guidelines” tab (above) as they are published. I view these sample guidelines as a group effort!  If you have a suggestion, critique or simply a better way to phrase some concept, say so in comments.

I wrote about food allergies previously on JailMedicine in “Food Allergies: Sorting Out Truth from Fiction” (found here). Since then, I have had more email requests for a Food Allergy guideline than all other sample guidelines put together.  It is clearly a BIG issue in corrections. 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