I was trying to mind my own business this morning and focus on my usual PowerPoints but then I happened across the musings of 1BOM and and some of his associations to an article on the fact that psychiatrists accept insurance at lower rates than other physicians. Interestingly, the authors look at some correlates of this phenomenon and then jump to the following conclusion:
"Nonetheless, our findings suggest that policies to improve access to timely care may be limited because many psychiatrists do not accept insurance."
The only way a sentence like this gets into a journal article is with the necessary qualifiers "suggest" and "may". Certainly the press and the detractors of psychiatry won't pay much attention to the qualifiers. I am sure that some managed care executives also see this as a reason for celebration. At a time when they literally have psychiatry on the run because of poor reimbursement, rationing, and invasive management practices - what better "research" to back up more managed care practices? It is not the onerous business practices after all, it is those pesky psychiatrists who refuse to accept whatever we want to pay them.
The authors of this article seem to ignore the historical context of 30 years of rationing psychiatric care to the point that inpatient care is generally of very limited value, psychotherapy-at least the research based kind is scarcely available, and psychiatrists trying to function in an outpatient settings are continuously harassed by insurance reviews or restrictions. Many public systems of care previously under the oversight of psychiatrists are now being run by administrators with no mental health training who have no shortage of ideas about how systems based care should be implemented. The authors provide an introduction to this research that contains the following paragraph:
"The Centers for Disease Control and Prevention estimates that a quarter of adults in the United States report having a mental illness at any given time and about half will experience mental illness during their lifetime. In the wake of the Connecticut school shooting and other recent mass shootings, policy makers and the public have called for increased access to mental health services. For example, President Obama’s “Now Is the Time” proposal, released in January 2013, called for better mental health services, including programs to identify diagnosable mental health problems early so that patients can be referred for treatment, and increased training of mental health professionals."
I really cannot think of a more politically naive statement about the state of mental health in this country or the likelihood that things are going to change. It is certainly clear to me that we have a standard strategy for mass shootings in this country that does not involve addressing the widespread availability of firearms or lack of availability of a functional mental health system. The public also seems quite content to accept the idea that violence and aggression are random acts and cannot be addressed from a psychiatric perspective. The usual photo-op involves politicians showing up, suggesting some serious political work (that never comes to fruition), praising the heroes and then suggesting that we must all move on. Occasionally there is the suggestion that people were just "in the wrong place at the wrong time". It is really nothing more than political helplessness in the service of career politicians and special interests. Torrey and Jaffe have taken a close look at what is wrong with the idea of a President's initiative on violence and aggression and there are many problems. Transmuting all of these chronic problems into psychiatrists not wanting to accept inferior reimbursement or the additional free work required for insurance business is ridiculous.
In the next paragraph the authors resort to a familiar stereotype of psychiatrists:
"Psychiatrists play an important role in the diagnosis and treatment of patients with mental illnesses particularly because of their training and ability to prescribe medications."
It is well known that 80% of all medications for mental health indications are prescribed by primary care physicians. Furthermore we are currently caught up in the latest managed care technology referred to as collaborative care that will greatly increase that percentage. That will be true because of an expected rapid increase in access to antidepressant prescriptions and also because in some models - psychiatrists will not actually see patients or write prescriptions. The real risk of eliminating psychiatrists is the diagnostic capability. There are many interests who benefit by not considering the importance of eliminating that skillset. Let me illustrate how that happens. For many years, I worked in a Geriatric Psychiatry and Memory Disorders Clinic. It was staffed by myself, by a neurologist, and an RN who specialized in geriatrics. We offered a service to primary care specialists and the community as a resource for diagnosing a full spectrum of cognitive disorders, dementias, and mental health disorders in geriatric populations. We also offered some research protocols and treatment with what was then state of the art medications for Alzheimer's disease. We also offered a full spectrum of referrals for psychosocial resources and residential care for patients that we saw and assessed. We were told at one point that reimbursement for our services did not cover the cost of nursing services for out clinic. Our nurse was an absolutely critical piece because she would gather information on the functional capacity, behavioral problems, and known medical problems of all patients coming in to the clinic. She would often gather this information from more than one informant. That would amount to about 8 hours of telephone work for one 4 hour clinic. Most of the time was provided free gratis because she believed in what we were doing. In order to possibly improve the financial status of the clinic, we started to travel out to nursing homes and see people there in person. That model was not useful because we received dramatically less reimbursement consulting in a nursing home setting. We also had unreimbursed travel time with each visit and the cost of transportation. Eventually administrators told us we had two choices - shut down the clinic or eliminate the nurse. It was an easy decision for the neurologist and myself. We barely had enough time to do all of the documentation associated with our services much less all of the collateral contacts. So we shut down the clinic.
This is a classic example of how quality mental health services are rationed and put out of business. Our clinic was well known for quality care. Years later I was still being asked about why we shut our doors. It is literally a function of how much information that you collect and analyze. In order to make the necessary diagnoses the full spectrum of functional capacity, cognitive, psychiatric, medical imaging, and laboratory data needs to be reviewed or ordered for the first time and analyzed. We would see people who were told by other physicians that "there is nothing else we can do for you" and they were wrong. There can alway be a debate about how much comprehensive services that utilize the full training and ongoing education of physicians is worth. It is definitely worth more than a 5 or 10 minute visit, a prescription and a Mini-Mental State Exam score.
1BOM list some associated arguments about the issue of whether psychiatrists should accept whatever insurance companies decide to reimburse. The most interesting of these is that the field can be parsed into basically psychotherapy and neurosciences. Further analysis suggests that if psychiatrists want to provide psychotherapy they should accept whatever standard reimbursement a "non-medical" therapist should accept. It is almost as if non-medical psychotherapy is an option in the training of psychiatrists. That attitude is certainly counter to the fact that psychotherapy is an integral part of psychiatric training both as a treatment modality and as a necessary technique for studying the therapeutic alliance. There are similar illogical arguments about transferring the neuroscience and neuropsychiatric aspects of psychiatry to neurologists. Dr. Nardo in his wisdom points out that basically neurologists don't want it. That is why they went in to Neurology in the first place. It seems that other specialists seem to know the demarcation of the speciality better than some psychiatrists do.
The overall problem here is very familiar to me. It is the reason I started writing this blog in the first place. Everybody has been bombarded by business and managed care propaganda for decades. One the the strategies contained in that propaganda is that medicine and psychiatry no longer define themselves. Business defines medicine. That is why all of my colleagues freaked out in the 1990s. They heard that "things are different now" and did not know what to do about that. Even today, the first reaction to the propaganda is to cannibalize your own specialty before thinking clearly about what this all means. Managed care closed down my valuable clinic because they said my valued nurse colleague was not "cost effective". Closing that clinic eliminated the availability of two experts who were providing services that were not replaced. Does that mean we have no need for geriatric psychiatrists, nurses, or neurologists? The headlines today would suggest otherwise.
We will all remain in the limbo of politicians telling us we need increased access and insurance companies decreasing access in order to increase their profitability. And that has nothing to do with the fact that psychiatrists need to be trained in neurology, neuroscience, medicine, and psychotherapy. Not accepting insurance is the ultimate affirmation that business does not define medicine or psychiatry.
George Dawson, MD, DFAPA
1: Bishop TF, Press MJ, Keyhani S, Pincus HA. Acceptance of insurance by psychiatrists and the implications for access to mental health care. JAMA Psychiatry. 2014 Feb;71(2):176-81. doi: 10.1001/jamapsychiatry.2013.2862. PubMed PMID: 24337499.
Supplementary 1: The issue of "financial viability" of my closed clinic came up on the 1BOM discussion. In my experience financial viability is just more managed care rhetoric. Like cost effectiveness it needs to be rejected outright. The most obvious evidence is the collaborative care model. Here we have a model that is strongly promoted by managed care and now the APA that is telling us that there are essentially unlimited resources to see what are called "med management" visits. They are after all eliminating any actual diagnostic process and putting people on medications as soon as possible. I am quite sure that some of the patients with complex problems that I assessed are now getting a PHQ-9 and placed on antidepressants. I have already posted that (based on 2005-2010) data that antidepressants are already being overprescribed. Collaborative care will result in a proliferation of additional "prescribers" to increase that number. For that questionable low quality service, the patient will probably be charged around $50 for (at the maximum) a 10 or 15 minute visit. In fact, in my health plan it can occur over the telephone with no actual patient visit. If I was in private practice I would probably charge $300-350 for a 60-90 minute evaluation that look at all of the patients medical, psychiatric, and medical imaging data. The final product is a diagnosis or list of diagnoses rather than a PHQ-9 score and there would be an intelligent discussion with the patient about what to do. If medications were prescribed there would be a detailed discussion of the risk, benefit, and likelihood of success. There would also be a detailed discussion of how to avoid rare but serious side effects and when the medication should be stopped and when I should be called if there were problems.
If you want to say that "financial viability" is a legitimate metric that exists outside of the mind of an managed care MBA, I would clearly disagree. My plumber, electrician, and chimney sweep don't hesitate to charge me $200 to show up and then add charges on top of that. The information content and technical skill they use to fix or install things does generally not reach the level that I would use in my 60-90 assessment. Financial liability in a managed care system is basically anything outside of high volume low quality work that the company can profit from. It is an artifact of cartel pricing that seriously discounts the skills of physicians. The only reason my tradesmen are financially viable is that they don't have a cartel fixing their prices, forcing them to put out a high volume, low quality product and skimming their profits.
I hope that more and more physicians stop taking managed care insurance and put the financial viability theory to a test. It certainly has not put tradespeople out of business and they are easily charging on par what physicians charge for reasonable medical care. We can also learn a lot from our dental colleagues who are usually subject to severe insurance limitations. I guess that by the managed care definition, dentists are also not financially viable?
My dentist by the way charges way more than I would charge in private practice.