Crowdsourcing Psychiatric Services

I heard a very compelling story on MPR Marketplace last night about crowdsourcing.  They interviewed the founders of Gustin denim and their new method for selling blue jeans.  The old way that most of us are familiar with is to design a certain type of blue jean or brand and then market that product to the public.  That marketing consists of convincing the public why they need the product.  There are many inefficiencies associated with that model including the fact that it is very difficult to match the product with the customer and there are charges for various middlemen added along the way.  Josh Gustin and his business partner Stephen Powell decided that there was a better way.  They decided to post fabric swatches and describe what they intended to do with it in terms of fabrics and then have prospective customers support these various "campaigns".  When sufficient number of subscribers was signed up they would produce the products.  The outcome of this process is highly efficient in that there is no wasted fabric for the manufacturer and no mark up for the customer.  These essentially custom blue jeans sell for $81 wholesale and are marked up to $250 by some retailers.  That allows the wholesaler to maintain the same margins by selling at the wholesale price.  What a deal all around.

Of course the first thing I thought of was this is an ideal way to match psychiatric (or any medical) services to what the public wants.  It would be a clinic or a coalition of independent providers.  Instead of being locked in to visits determined by billing codes that don't really match very well with what patients or physicians want, the entire spectrum of services could be offered.  The pricing structure might be a little more complex if various insurances are factored in but consider the ideal case of no insurance and strictly cash payment.  There is often a lot of confusion over how long the visits last and what exactly happens in the visit.  As an example,  it is common for patients who are used to seeing a psychiatrist for 30-60 minute visits suddenly going to a different clinic and being told that they can see the doctor for only 10-20 minutes.  They have similar problems with frequency.  Even in an initial assessment, the patient may have an expectation that they have 90 minutes of history only to be told that the doctor only sees people for 40 minutes and uses the last 20 minutes for dictation.

A menu of services could be offered on an ongoing basis with a critical mass of subscribers determining any significant changes.  I would also have a menu of consult questions and conditions of varying complexities.  This would be quite an exciting approach given the state of outpatient services and how they are currently determined.  I mentioned a completely unrealistic set of billing codes as being one determinant.  Do you need to see the doctor for a "med check"?  The other is managed care and their unrealistic productivity and rationing demands.  If a person is being seen in a clinic where every doctor is allotted 10-20 minutes they may appear to be poised over a prescription pad rather than being a source of information and discussion.  Some services that would be in demand are not even offered and the justification is that they are "not medically necessary".  It should be possible to offer the rationed version of services along with a more complete version of what people may want.  I would also tend to list research proven services.  One of the main problems is that psychotherapy services are often in the mind of the therapist.  I have listed several research proven approaches on this blog.  When I talk with people who I have assessed about what I think they need, I discuss psychotherapies that have been proven to be effective for their particular problem.  The difficult part is for them to find a person providing that kind of therapy.  If should be clearly listed rather than referenced as an interest in the employee bio section of the clinic web site.

Some people (like managed care executives and the government bureaucrats who support them) will say that we cannot give patients this level of input into the design of psychiatric or medical services.  It will just not be cost effective and they will be asking for many "unnecessary" services.   In my experience talking with people over thirty years that is clearly not the case.  It turns out that most people are reasonable and make rational choices.  Some people will insist on the shortest and most cost effective approach.   Others realize that they get a lot more out of discussions than a prescription.  They find that even a 20 minute conversation about a medication is not long enough.  Some want to show up with a written list of problems for discussion and they don't want to be told that they need to set up separate 10 minute appointments for each problem.  Everyone has an expectation of service and I can't imagine that most people are currently getting it.  With crowdsourcing customer satisfaction would no longer be a joke.

Customer satisfaction would start with the design of services and their availability rather than a scripted survey designed by a managed care company to make them look good.  How else can you end up rating suboptimal, highly rationed and inaccessible services highly?  Aren't 95% of all managed care clinics and hospitals highly rated?

We are all unreasonably taxed for health care services.  It is time to let the crowd design what they want.  They are paying a very high price for it.

George Dawson, MD, DFAPA

Supplementary 1:  I hope to come up with  crowdsourced menu and post it here in the next few days.