What Does “Medically Necessary” Mean?

Let’s say one of my jail patients has a moderate-sized inguinal hernia.  I want to schedule surgery to have the hernia fixed, but to do so, I have to get authorization.  This is not unusual.  Just like the outside, before I can do medical procedures or order non-formulary drugs, I must get the approval of the entity that will pay the bill.  By contract, my jails house inmates from a variety of jurisdictions, such as the Federal Marshals, ICE, the State Department of Corrections and other counties.  This process of “Utilization Management” is very similar to getting pre-authorization from an insurance company or Medicaid in the free world, probably because Corrections simply copied the outside pre-authorization process.

Having done this process hundreds of times over the years, both in the free world and in Correctional Medicine, I am struck by a phrase that keeps coming up: “medically necessary.”  When authorization for a procedure is denied, the reason often given is that it is “not medically necessary.”  I then have to argue that what I am requesting is, indeed, medically necessary.  The problem is that there are many possible definitions of “medically necessary,” and I believe many disagreements arise because two parties understand “medical necessity” differently.

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Documenting Test Results the Ed and Midge Way

I have a ten-year-old Yorkie named Ed. Ed is experienced and knows the daily routine of our house. Last year, we got a Yorkie puppy named Midge. She initially knew nothing.  It has been entertaining to watch Ed educate Midge on what to do. Midge watches Ed closely and then does whatever Ed does. She is a true Ed Mini-Me. If Ed lays down, Midge lays down.  If Ed asks to go out, Midge wants to go out, too. If Ed begs for a treat, so does Midge.

Since Ed is a pretty good dog, most of what he has taught Midge have been good things, like ask to go outside when you need to potty and sit to say “please” when you want a treat.  But Ed also has some bad habits that he has imparted to Midge.  Ed still has the Yorkie propensity to yap at the door when the doorbell rings, and so Midge has also learned to also sound the alarm.

Medical education is like this. I remember being a young dog medical intern and watching my heroes, the senior residents. Not everything in medicine is taught in medical textbooks and didactic lectures!  Much of what we actually learn as medical practitioners is an imitation of our elders.  For example, I watched what the senior residents ate (junk), when they slept (rarely) and how they treated nurses (some good, some poorly), among other things. Like Ed, most of what my senior residents taught me by example was good. But there are a few sketchy practices handed down from medical resident to medical student that can become bad habits.

Ed: Do what I do. Midge: Ok!
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Gabapentin for Musculoskeletal Pain?

At one of my recent jail medical clinics, three patients in a row requested prescriptions for gabapentin.  One was a patient newly arrived from the Idaho Department of Corrections to be housed at my jail due to prison overcrowding.  He had already been prescribed gabapentin at the prison for complaints of low back pain radiating to one leg and wanted me to continue it–forever.  The second patient was prescribed gabapentin by his outside practitioner for a boxer’s fracture that had been surgically repaired years ago.  The third was prescribed gabapentin at a previous jail due to “nerve damage” from an old gunshot wound to the upper arm (he had a large scar but no functional disability or decreased sensation).

Gabapentin prescriptions for nonspecific musculoskeletal pain have clearly become common in the community and in corrections.  These three patients represent only a fraction of the similar cases I see in my jails! I suspect that this gabapentin-mania is being driven by a belief that gabapentin is preferable to prescribing narcotics (though I would not think any of the three patients above would be candidates for narcotics).  Gabapentin, in fact, is often prescribed for musculoskeletal pain in my community first line—before NSAIDS and Tylenol, even—and many, like these three patients, subsequently believe that gabapentin is something they will need to take for the rest of their lives. 

The problem is that prescribing gabapentin for musculoskeletal pain is not evidence-based and (in my opinion) bad medicine.

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Top 2018 Medical Research Articles for Corrections

One thing I look forward to each day is looking through my medical feeds that keep me up to date with medical research.  Most of this content ranges from bogus to unhelpful (in my opinion), but every once in a while, a truly game-changing article appears.  Over the years, I have noticed that most of the game changing articles are debunking articles.  They show that something that is commonly done in medicine actually has no value.  I love these!  Not only do they improve the medical care of my patients, they also make me more cost-effective.  As I have said before, the main way to save money in Correctional Medicine is to eliminate (and stop paying for) medical practices that have no value—or even worse, are harmful to patients.

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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

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

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

Do Uncomplicated Lacerations Need To Be Closed Within Six Hours?

Dr. Keller,
What do you think of the rule for lacerations that says a laceration has to be sutured within six hours or it cannot be sutured at all? At our facility, we send lots of inmates to the ER for simple cuts because the PA isn’t scheduled to be at the facility until the next day. If a cut is 10 hours old, why can’t it be fixed?  Where did this rule come from?
Kim A.

Thanks for the question, Kim. The short answer to this question is that that this belief is a myth. Uncomplicated lacerations can, indeed, wait more than 6 hours to be repaired.

“There is a common misconception that all wounds must be either sutured within a few hours or left open and relegated to slow healing and an unsightly scar.”  Roberts and Hedges’ Clinical Procedures in Emergency MedicineUnknown

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Do Not Use Hydroxyzine for Alcohol Withdrawal!

We correctional practitioners get to see a wide range of medical practice as we review the medical histories of inmates arriving at our facilities. I myself have seen many prescribing practices that make me scratch my head. One example I have run into repeatedly is the practice at many jails of using hydroxyzine to treat alcohol withdrawal.  It turns out that many jails do this.  I am not talking about hydroxyzine as an adjunct or an add-on to the primary agent. I am talking about hydroxyzine being used as the primary treatment agent itself.

In my opinion, this is a mistake, and should be stopped.

Now I admit that there is room for dissention in medicine. Not all practitioners practice in the same way and there are many, many areas of medicine where there is no right answer. And it is true that hydroxyzine was used in the 1960’s to treat alcohol withdrawal. However, since then, medicine has discovered superior agents to treat this condition: the benzodiazepines. Today, hydroxyzine is the wrong agent for alcohol withdrawal. If your facility uses hydroxyzine as the primary treatment for alcohol withdrawal, you should change your protocol. There is no legitimate basis for this practice.images Continue reading