Medical Ethics and Managed Care

Managed Care Psychosis

Lawrence R. Huntoon, MD, PhD


Recently, I was asked to see a patient in neurologic consultation because he had reportedly displayed "irrational behavior." He had been admitted to the locked psych ward with a diagnosis of psychosis not otherwise specified which translates to "haven't the foggiest idea what's wrong, but I think he's crazy." He was a very pleasant, soft spoken elderly man and after I introduced myself, he sat down and calmly related the following story.

"You see, it all started, Doc, when I joined that HMO. I was doing just fine with my regular doctor. My doctor had been very careful and thorough in doing tests for my condition. My heart problems and high blood pressure problems were under good control. But then, one of my friends told me how little he was paying for his health coverage, and it sounded good to me so I joined the HMO."

The patient's regular doctor, of course, wasn't on the HMO's list, and the patient was subsequently assigned to an approved HMO doctor. All of which wasn't a problem, of course, until he had a "spell" which, in all fairness to the psychiatrists, is the neurologic equivalent of "haven't the foggiest idea what's wrong, but I think it's neurological." He subsequently went to the ER where they did an EKG and apparently told him that he had something wrong with his heart. They suggested he make a follow-up appointment with his physician. When the patient called his assigned HMO doctor, however, he was told that they "didn't know him and he wasn't on their list." This, of course, led to a number of calls to the HMO from the patient's family and after a number of days of searching and updating their lists, he was finally able to get in to see his new HMO doctor.

In the meantime, however, he had apparently been ranting and raving about all of the difficulties he had getting medical care under the HMO which, after a suitable time, became labeled as "irrational behavior." His HMO doctor, who didn't know the man, briefly listened to his heart and told him there was nothing wrong, stopped his BP medication which the patient's original doctor had spent so long adjusting just right. The patient felt that was irrational, of course, and began more ranting and raving about his HMO care which, of course, supported the original conclusion that he was acting "irrationally." He then explains he just couldn't take anymore that same day when he learned that US\NATO forces had bombed the Chinese embassy in "Clinton's private war" in Kosovo. "Don't they know that such things could lead to WWIII?" And, all of this from a president who argues what the meaning of the word "is" is. He said, "I think that's all rather irrational, don't you Doc?" Of course, this all led to further ranting and raving which ended up buying him some quiet time for thoughtful introspection in the psych unit which, in turn, led him to the enlightened conclusion that it is eminently "more rational" to keep one's opinions to oneself when it comes to HMOs and irrational presidents. Toward the end of the examination as I strained to find some scintilla of true irrationality, he imparted one final piece of logic: "I must be irrational or I wouldn't be here in the psych unit."

At that point, of course, I realized I was also behind the locked doors of the psych unit and although I have made the ethical decision not to participate in managed care, there are undoubtedly many around me who would say that given the present health care environment, my choice not to be an HMO doctor is irrational. Introspection and empathy being somewhat of a contagious thing in such a setting, I felt that it would be best to leave before someone could dig out my managed care commentaries in previous issues of the Medical Sentinel. The sound of the buzzer unlocking the door so I could leave was most reassuring as I figured that they wouldn't let me out unless I was rational...right?

Ultimately, the man's CT scan showed a small lacunar infarct that may very well have caused some confusion and disinhibition in expressing his opinions. There is no question in my mind, however, managed care or more appropriately "mangled care," was the proximate cause of this man's week of confinement in the psych unit. His HMO doctor, who no doubt felt that it would be more cost effective not to consult a neurologist, stopped the anti-hypertensive medication prior to the patient's admission to the hospital thinking that it was the cause of the "confusion." This led to a short stay in the ICU for accelerated hypertension. And, hypertension, being the likely underlying etiology of the lacunar infarct, we note treatment of high BP in this setting is the only rational preventive treatment that can be offered.

In the end, the HMO paid for the psychosis which the HMO itself provoked which, although not cost-effective, is likely the only rational part of this story. In the evolution of managed care terminology where patients become (de)capitated heads, it is now clear the most accurate term for HMO enrollees is victim. As there is no code in the ICD-9 manual to cover this man's situation, however, I propose adding a fifth digit to an existing code so his condition can be coded to the highest degree of specificity. Thus, 298.82 shall henceforth be known as situational (reactive) psychosis due to dysfunctional managed care...unless, of course, someone opines that that would be irrational.

Dr. Huntoon is a neurologist in Jamestown, New York and AAPS president.

Originally published in the Medical Sentinel 2000;5(1):29. Copyright©2000 Association of American Physicians and Surgeons (AAPS)