Top Prescribers: Do Medical License Restrictions Have Unintended Consequences?

Dr. Steven Balt, editor-in-chief of the Carlat Psychiatry Report, recently found himself on the list of top prescribers for a psychiatric drug billed to California’s Medicaid program in 2009.

He says that he prescribed a lot of medications that year because that was the culture at the Bay Area clinic where he worked. He says he disagreed with that culture, but then why did he work so long – 2008 to early 2012 – in a clinic where he felt the care was substandard?

One big factor was that in 2005 he had been placed on probation by the Medical Board of California because of two shoplifting charges and a driving under the influence charge. Balt talked to me in January 2011 about how a lifelong struggle with bulimia nervosa led him down a path of risky behaviors.He said at the time, the bulimia “proved to be my undoing.”

Balt says now that the effects of that Medical Board case were still being felt when he worked for the Bay Area clinic:

As an independent contractor myself with that clinic, I could have left at any time and probably should have, since their practices did not align with my professional ethics. But this was my first "real world" experience, and I told myself that my expectations may have been far too idealistic. More importantly, though, I could work nowhere else. As your readers may recall from your interview with me, after I left Stanford [Hospital’s residency program] I was in no man's land. I was still licensed as a physician, but I was in the Medical Board’s diversion program [for doctors with substance abuse or mental health problems], until that program was ended.  I had not yet finished residency so my options were extraordinarily limited. Several California residency programs with openings between 2008 and 2011 were unwilling to hire me.  The only reason I worked at the clinic was because it was, literally, the only place I could find that would permit me to work as a psychiatrist.

And now here’s the scary part.

Balt says he thinks that he was just one of many doctors in duress who take jobs that other physicians don’t want, often dealing with vulnerable populations. I have written about this before, with doctors being funneled into treating low-income patients or prisoners as part of their discipline by state medical boards.

And then there are the no-other-options doctors, like Balt describes. These are the doctors you may remember from The Shadow Practice series. In my interview with Dr. Scott Bickman, he described how he ended up in trouble with the U.S. Drug Enforcement Agency for allowing another doctor to use his DEA privileges to order massive volumes of painkillers that then went unaccounted for. One of the only places he could find a job was in a 1-800-GET-THIN Lap-Band clinic that later was slapped by the FDA.

Balt now has a full and unrestricted medical license in California. But, his experience demonstrates that a Medical Board history can severely curtail a doctor’s employment prospects:

In my job searches over the past year, I have found that physicians with license restrictions have extreme difficulty finding regular work, regardless of their ethics or philosophy. As a result, they may be drawn to positions like the one in that clinic or crisis medication clinics, or performing quick disability evaluations or group home visits. As a result, many of our disciplined or reprimanded physicians are working in the highest-volume settings, which may severely compromise care. Of course, we also have fully licensed and "pristine" physicians practicing in these settings and overprescribing, too, but that's an entirely different matter.

So does Balt still prescribe antipsychotics and other drugs in high volumes? Not at all, he says.

In my own case, I recently completed my residency and passed my Boards, and I have opened my own private practice in the Bay Area. It has been slow thus far, but I fully believe I can succeed because I feel confident in my ability, and I get great feedback from my patients. The Medical Board’s action against my license had nothing to do with the quality of my patient care, and I have always been committed to treating each patient as a complete person, not just a collection of symptoms. On my own, I feel that I'm practicing a different type of medicine than in the high-volume medication clinics I've seen in the past. I'm treating the same sorts of people, but I am not restricted by documentation requirements, time demands, formulary restrictions, or an overflowing waiting room. I do prescribe antipsychotics, but not without a careful assessment of risks and benefits first. This is the psychiatry I was taught to practice.

Stephany at Soulful Sepulcher, one of my most vigilant readers when it comes to mental health issues – and the blogger who first started writing about Balt being on the list of top prescribers – suggested that I ask Balt about Medicaid. So I asked, “Because you and the clinic were billing Medicaid for Seroquel, a name brand drug, versus a cheaper drug, do you feel like this was abuse of the Medicaid system?” Here’s what he wrote:

Yes. But keep in mind, if billing for Seroquel is "abuse" of Medicaid, then I would also state that there were similar abuses of Medicare, Social Security Disability, State Disability, Workers Comp, In-Home Support Services (IHSS), etc., and that such abuses were not limited to this one clinic.

One final note. You may notice that Balt deleted some of the tweets I wrote about on Monday (and that Stephany has posted on her blog). The social media world tends to punish deletions as something akin to homicide. But is there room for error on Twitter? I’d love to hear your thoughts on when it is acceptable to remove a tweet and whether it is any different than deleting an email or throwing out an early draft of a document that you shared with people and then revised. Send me a note at askantidote@gmail.com, leave a comment below or find me on Twitter @wheisel.

Image by Joe Houghton via Flickr