Treatment divided among psychiatrists and mental health professionals is becoming the norm in managed care systems, but it is fraught with dangers for both patients and psychiatrists.

Without appropriate safeguards and policies, psychiatrists entering such relationships face ethical, clinical, and legal risks, according to Jeremy Lazarus, M.D., speaker-elect of the Assembly, past chair of the Committee on Ethics, and a consultant to the Managed Care Committee.

"Psychiatrists are often pressured or given financial incentives to provide only medication management during visits of 15 minutes or less per patient, which can lead to inadequate collaboration with the patient's psychotherapist," he said at a symposium cosponsored by APA and the APA Auxiliary at APA's Institute on Psychiatric Services in Chicago in October.

Lazarus presented actual and hypothetical cases involving ethical problems and the actions taken or that he predicted would be taken by DB ethics committees. Helpful in such decision making, he said, are the AMA Principles of Medical Ethics With Annotations Especially Applicable to Psychiatry and APA's Guidelines for Psychiatrists in Consultative, Supervisory, or Collaborative Relationships With Nonmedical Therapists, which is being updated.

When a psychiatrist assumes a collaborative or supervisory role with another mental health professional, he or she must spend sufficient time to ensure proper care is given and cannot be used as a figurehead, states APA Annotation 5, Section 3.

A case that did not meet these conditions involved a psychiatrist who worked at a busy public clinic and left signed prescriptions for mental health professionals to fill out at the administrator's urging. In addition to the DB sanction, the state medical licensing board took action against the psychiatrist.

APA Annotation 5, Section 2 states that when psychiatrists refer patients for treatment to an allied health professional or paraprofessional, they should ensure that the individual is a recognized member of his or her discipline and competent to perform the necessary therapeutic tasks. When in doubt, the psychiatrist should not refer patients to him or her.

In another case, this one hypothetical, a psychiatrist relied on the managed care company's credentialing process to assure competency of the health professionals to whom she referred patients. She learned through a newspaper article that one of the company's therapists was charged with sexual misconduct by three of her patients. The psychiatrist was sued for malpractice on the basis that she should have known that the therapist was incompetent. The local DB might have concluded that if she had maintained adequate collaboration with the other therapists, she might have been alerted to the misconduct, said Lazarus.

He urged each profession to advocate for payment of professionals for collaborative or supervisory time and for treatment standards beyond the absolute minimum for patient safety.

APA legal counsel JoAnn Macbeth said nearly all liability exposure in malpractice cases is because of negligence. She recommended strategies to avoid such exposure (see box).

"In psychiatry," she noted, "negligence involves the failure to obtain adequate information about the condition and circumstances of the patient and the failure to give adequate time and attention to the decision of a treatment approach."

Macbeth said divided treatment arrangements frequently make it difficult to satisfy these two conditions.

Moreover, if you make a mistake, "you must prove that you took a lot of time reaching the wrong conclusion," she said. This is because jurors "do not like the idea that, for want of a few extra minutes or reading an extra article, they could be severely damaged by a physician."

A hypothetical case in point involved a psychiatrist hired by a managed care company to work a 10-hour week. He saw four to six patients an hour for medication management as a consultant to 30 mental health professionals. Because of time pressures, the psychiatrist failed to adequately evaluate new medications he prescribed for a patient with a complicated medical condition. Subsequently, the patient developed severe side effects.

"This case has all the earmarks of a significant plaintiff's verdict," said Macbeth. "The critical knowledge was readily available, yet the psychiatrist didn't take the time to obtain it."

The DB ethics committee might have concluded, said Lazarus, that the psychiatrist had an ethical obligation to protest the system that did not give him adequate time to ensure that patients receive competent treatment and to work overtime or treat patients without compensation if necessary.

Macbeth also commented on the case example of the psychiatrist who left signed blank prescriptions for health professionals to fill out. "You are legally responsible for the treatment of every patient for whom you prescribe, and you must provide the same time, attention, and care as you would any other patient you treat."

Lazarus and Macbeth have stated that they are available to speak to district branches on the ethical and legal issues related to divided treatment.

How to Protect Yourself

Psychiatrists in divided treatment arrangements can minimize liability exposure by following these strategies, according to APA legal counsel JoAnn Macbeth.

• Take enough time to evaluate the situation carefully and update information.
• Familiarize yourself with the operations and routines of each practice setting. Who does patient intake? Is there a gatekeeper? How often is patient information updated?
• Screen current and new practice sites by looking at staff turnover and the non-MD staff screening and peer review responsibilities.
• Look at other health professionals' credentials and disciplines and what provision is made for consultation.
• Know how to appeal a denial of benefits--the law requires you do everything possible on the patient's behalf.
• Coordinate patient care from the outset with the collaborating mental health professional.
• If supervising a mental health professional, agree on a schedule that meets the patient's needs and what information you expect from him or her regularly and in emergencies. Document this.
• See patients according to their needs. Prescribe medication for the number of days you feel comfortable with and don't change it.
• Read and/or have your lawyer read the managed care contract carefully. Ask about indemnification provisions that expose you legally and financially in malpractice lawsuits.
• Ask whether you would be the "deep pocket" in malpractice lawsuits. This can result from statutory law, managed care indemnification, or having insurance.

(Psychiatric News, December 20, 1996)