Kaiser Drug Policy Prompts State Inquiry

Kaiser Permanente, the state’s biggest health maintenance organization, routinely requires its psychiatrists to prescribe psychiatric drugs to some mental health patients whom they have not personally examined, a practice that leading experts say endangers patients and violates professional codes of ethics.

State regulators are investigating complaints that Kaiser may be running afoul of long-established medical procedures by requiring psychiatrists to prescribe medications for depression and anxiety at the recommendation of nonmedical psychotherapists, such as social workers and social-work interns.

Both California law and the American Psychiatric Assn. code of ethics declare that prescribing drugs without a “good faith” prior examination is unprofessional conduct.

Kaiser’s little-known policy has come under attack in a lawsuit filed this week by a former Kaiser psychiatrist who was fired for refusing to prescribe medications for patients whom he did not personally examine. The physician, Dr. Thomas S. Jensen of San Diego, has asked a state court to halt Kaiser’s practice.

Based on complaints by Jensen and another Kaiser psychiatrist in Sacramento, the state Department of Corporations has begun investigating the practice, a department spokeswoman said.

Jensen said he told state regulators that he saw cases where nonmedical personnel had recommended drugs that could have jeopardized patients’ health.

Kaiser, which has 30 days to answer the allegations in Jensen’s lawsuit, acknowledged that its policy differs from standards generally accepted by the psychiatric community. But Dr. Dennis Cook, coordinating chief of psychiatrists for Kaiser’s Southern California operations, defended the procedure, saying that it allowed Kaiser’s psychiatrists to see more patients by eliminating a potentially duplicative initial interview.

Cook said the contention that the practice was unethical was self-serving on the part of psychiatrists in private practice, who don’t know and trust the therapists making the recommendations, and who stand to make money from an extra office visit.

“We think it’s very ethical,” Cook said. He denied that any injuries have resulted from Kaiser’s policy.

Some of the nation’s top psychiatrists, contacted by The Times, said Kaiser’s policy of allowing nonmedical personnel to examine patients and recommend drugs stopped far short of the competent standard of care.

Social workers, family therapists and social-work interns are not trained to know the risks, benefits and side effects of psychotropic drugs, the experts say.

“It’s not trivial to put someone on psychotropic medications,” said Dr. Joseph T. Coyle, chairman of the department of psychiatry at Harvard Medical School. “If you haven’t evaluated the patient when you start the treatment, then it’s impossible to follow the patient and see how [he or she] is responding to powerful drugs that could cause harmful side effects.

“I’m surprised that an ethical insurer would require such a practice,” Coyle said. “They say California tells what the future is. I hope that’s not the case for the psychiatric practice.”

William Baak, a psychiatry professor at UC San Diego School of Medicine, called the HMO’s policy “outrageous.”

“If that’s modernity, I don’t want any part of it,” Baak said.

And Dr. William Arroyo, a psychiatry professor at USC School of Medicine and a member of the APA’s ethics committee, said Kaiser’s practice clearly violates the professional body’s code of ethics.

“This undermines patient care,” he said.

The state investigation and the whistle-blower suit focus in part on Kaiser’s contention--made in advertisements--that “physicians alone manage all aspects of care.”

“At Kaiser Permanente, medical decisions are made by physicians in consultation with their patients, not by health plan administrators,” Kaiser states on its Web site. The HMO’s doctors “can order any tests, medications, medical procedures or referrals they need without approval from someone in the health plan.”

Cook defended the claim, saying that psychiatrists can refuse to prescribe drugs if the case does not seem to warrant it--as long as they agree in principle to prescribe drugs without examining patients in cases that the HMO views as cut-and-dried.

Although children and adolescents are seen by psychiatrists before drugs are prescribed, adults typically are not, Cook said.

Instead, they undergo an evaluation by a therapist--generally a psychologist or social worker, but in some cases a social work intern, Cook said. If their answers to a preset list of questions appear to indicate that they suffer from depression or a temporary form of anxiety called situational anxiety, the therapist presents these findings, along with the patient’s medical chart, to the clinic’s on-call psychiatrist.

‘I Was Astounded That This Was Happening’

If the psychiatrist does not detect anything on the medical chart that would indicate that the patient should not have an antidepressant such as Prozac or another psychiatric medication, the physician writes the prescription, Cook said.

The patient is then given a follow-up appointment with a psychiatrist, generally to be held three to four weeks later, and instructed to phone Kaiser if any side effects develop.

Cook said patients with other psychiatric or psychological conditions must see a psychiatrist before medication is prescribed.

He said that Jensen knew about Kaiser’s practices before he signed on.

“When we interviewed Dr. Jensen, we made it very clear to him that this was our practice and style,” said Cook, who heads the San Diego clinic where Jensen worked. “And we said, ‘It’s not for everyone.’ ”

Jensen, a 1986 graduate of the UCLA School of Medicine who said he closed a successful practice in Lewiston, Maine, to take the Kaiser job, denied that.

Jensen said that on his first day in Kaiser’s San Diego clinic, he was presented with cases by social workers, social-work interns, and marriage and family therapists who recommended drug treatments for patients they had diagnosed.

“I was astounded that this was happening,” he said. “I was trained that you don’t prescribe medicines for patients you’ve never seen.

“In my view this was worse than Internet doctoring because at least most of doctors [who treat patients on the Internet] have an e-mail exchange with the patients,” he said. “In these cases, I had no contact at all.”

Jensen said he saw cases where nonmedical personnel had recommended drugs that could have jeopardized patients’ health. In one case, a therapist recommended--and a psychiatrist prescribed--a specific antidepressant for a bulimic patient even though medical evidence suggests that people with bulimia suffer seizures at a higher rate when placed on that drug.

In other cases, he said, patients were placed on powerful psychotropic medications and provided with drug refills for up to three years without a single follow-up doctor’s examination.

Jensen said he approached his colleagues and supervisors who assured him the practice was proper. That assertion conflicted with opinions Jensen received from some of the top psychiatrists and ethicists in the field.

Jensen was fired in December when he refused to back down, but his bosses told him he could stay on until he found another job.

Jensen, who now teaches part time at UC San Diego’s medical school, said he knows that his lawsuit will have a negative impact on his career.

“I’m completely confident that I did the right thing,” said the 40-year-old psychiatrist. “If someone went on an antidepressant, became agitated and backed up on a freeway or shot up a schoolyard I could not have readily accepted myself.

“As a physician I was required not only to refuse to do this, but to do what I could to end the practice because it endangered patients.”

Cliff Palefsky, a San Francisco lawyer representing Jensen, said he might file an employment suit on the psychiatrist’s behalf. But Palefsky said Jensen’s first goal was to alter the Kaiser policy.

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The insurer settled a Texas lawsuit over patient care. C1