Tuesday, October 21, 2014

Nice Survey - Wrong Conclusion

There is a survey study of ease of getting and appointment with a psychiatrist in this month's Psychiatric Services.  The researchers called psychiatrists offices in three major cities in order to get an appointment.  They wanted to assess the degree of difficulty and whether or not payer source would be a factor.  Of the total calls only about 25% resulted in an appointment.  The reasons are listed in two tables in the article that is available on line.   Interestingly  there was no big difference  between private pay payer sources and insurance or Medicare in terms of getting appointments.  Given the movement of psychiatrists out of employee systems and Medicare based systems that was surprising and suggests to me a possible sampling flaw in the study or an artifact of the low return rate.  The flaw could be that the researchers looked at a Blue Cross Blue Shield (BCBS) web site and called lists of in-network providers in Boston, Houston, and Chicago.  The authors in this case do a reasonable job analyzing their limited data.  In their discussion of possible solutions they fall short of possible solutions.

In this case a key assumption is that the inability to set up appointments with psychiatrists implies there is limited access and this in turn means a shortage of psychiatrists.  We are hearing this argument at a time when managed care organizations like BCBS are basically saying that patients can receive psychiatric care in a primary care clinic.   In fact, BCBS was one of the early adopters of the PHQ-9 based Diamond project, where PHQ-9 scores formed the basis of a depression diagnosis in primary care clinics and the focus was optimizing antidepressant prescriptions based on those scores.  Where does an appointment to see a psychiatrist fit in that type of care?  Does collaborative care mean collaboration with a psychiatrist for every 500 or 1,000 or 10,000 primary care patients with an elevated PHQ-9 score?  Are patients in systems of mass care likely to seek psychiatric consultation?  In many algorithms of similar integrated care, some systems are set up to avoid psychiatrists completely, including the psychiatrist who is doing the psychopharmacological consultation.   How would such a system of care bias patients against psychiatrists and would psychiatrists be more dependent on other referral sources? And most importantly, wouldn't we expect limited access to a group of psychiatrists designated as in-network providers for a managed care company?  This is after all what managed care companies do.  They provide disincentives for physicians to see patients.  Managed care is a rationing mechanism.  It does not surprise me at all that physicians operating in that environment are difficult to see.

The authors propose that there are a number of ways to get medical students interested in psychiatry and that this would potentially solve the problem.  I don't know how that would work if there are already psychiatrists out there who are either working too hard or not interested in seeing new patients or referrals.  There was also the issue of psychiatrists being listed with incorrect phone numbers in over 10% of the cases.  It would also be interesting to note if the psychiatrist contacted agreed that he or she was actually in the network of care being described.  Many psychiatrists have told me they were in networks or panels that they had never agreed to participate in.

As I have previously stated, I don't think it is a question of recruiting more people in to psychiatry.  That approach ignores the state of crisis that the field is in right now.  That crisis involves the government and managed care companies dictating what psychiatric care is.  It also involves the American Board of Medical Specialties dictating what they think psychiatrists need to do for ongoing professional education.  It involves professional organizations - both the American Psychiatric Association (APA) and the American Medical Association (AMA) abandoning their member practitioners for what appears to be short term political gain.  The first thing lost to the politicians and businessmen  has been the practice environment.  Being a physician is more and more like being an assembly line worker.  Physicians are accountable to managers with no medical knowledge and no professional standards.  All of these developments have clearly demoralized physicians.

Taking a look at one of the suggestions, an interesting one was the suggestion that exposure to psychodynamic therapy increases medical student choice of psychiatry as a speciality field.  There are a few problems with that theory that are consistent with the deterioration of the practice environment.  It is certainly unlikely that any trained psychiatrist would make their expected productivity numbers for employees by doing psychodynamic psychotherapy.  It is currently practiced strictly in private settings or as supplementary activity once the productivity expectations are met in other endeavors.  Some psychiatrists have a psychotherapy practice "on the side" of their main employment.  It is highly unlikely that hospital or clinic environments are psychodynamically informed settings anymore or that residents learn how to manage those problems.  Many of those environments are a set up for split treatment.  Using psychodynamic psychiatry to sell residency to medical students seems like an informed consent issue to me.   Sure we will train you in it and supervise you doing the therapy but good luck practicing it in the real world.  I could put together a program that medical students would flock to, but they would never be able to use what they learned in a dumbed down practice environment.

You cannot have a profession that allows itself to be defined by hack politicians and businessmen with their own for-profit agenda.  Unless organized medicine and psychiatry focuses on that basic element, everything else is rearranging chairs on the deck of the Titanic.  Successfully rationing care does not mean there is a shortage of doctors.  It may mean the doctors just find the cost of doing business with a particular insurance company so high that they would prefer to see fewer or no patients from that payer.

It is absolutely mind blowing to me that nobody else can see that.

George Dawson, MD, DFAPA


Monica Malowney, Sarah Keltz, Daniel Fischer, J. Wesley Boyd; Availability of Outpatient Care From Psychiatrists: A Simulated-Patient Study in Three U.S. Cities. Psychiatric Services. 2014 Oct (early online release).


  1. I agree with this article entirely except for one minor point:

    "It involves professional organizations - both the American Psychiatric Association (APA) and the American Medical Association (AMA) abandoning their member practitioners for what appears to be short term political gain."

    I don't even see what the short term political gain is unless it's just feeding the ideology that medicine for profit is bad. I think these organizations are run by echo chamber academics who are indifferent and or hostile to private practice. I think the APA is full of utopians who believe in the perfectibility of humans (which I find bizarre in anyone who understands human behavior) and society. Psychiatrists are complete hypocrites and politically naive. They support ACA but most will never accept the low reimbursement that comes with that. Which is why most psychiatrists are off the grid and cash only. While supporting the grid. There's a lot of magical thinking going on in the field.

    1. My experience has been that special interests and schools of thought are always active in professional organizations. The main reason why the APA (with the exception of Harold Eist) and the AMA became so managed care friendly at the outset was members inside of the organizations promoting the idea that "all is lost" if we don't get on the political bandwagon. We are seeing the exact same thing happen with collaborative care and both organizations caving in to the PPACA. So I see the politicians and not the Utopians and I don't see the needs of the average member trying to make a living being accurately represented.

  2. Both are also de facto publishing empires. Royalties are a big motivator and APA seems far more interested in DSM revenue and AMA in CPT revenue than actually fighting managed care, EHR or MOC. In fact, many of the leaders are pro-MOC and involved with it.


    But I blame this on the members for being too passive....

    1. I tend not to blame physician members any more than I blame tax payers. The current model for democracy is an oligarchy with the oligarchs reminding us all that they are elected representatives and therefore they are entitled to make what ever decisions they see as bing fit. As a publishing empire, the APA is on shaky ground. They get an infusion from a DSM about every 20 years. In the meantime, they are publishing books for psychiatrists without really investing in the audience. The products are generally for early career folks who are not up to speed on using the literature in clinical practice. Most of the texts do not give psychiatrists in practice what they need to make complicated clinic decisions on a daily basis. If I am reading the annual reposts of both APAs correctly the American Psychological Association generates more revenue in licensing than the APA does in publications.

      They need a psychiatric version of UpToDate as soon as possible, but even then it will not do them any good if on the other hand they are saying that psychiatry is sitting in a little room in a primary care clinic and looking at PHQ-9 scores. A solid high tech product like UpToDate is superfluous if your are not going to actually see and treat complex patients.

  3. Under Collabo-Care, with a little tweaking, UpToDate can basically be used to replace the psychiatrist. Why pay someone 250K a year to read something the GP can read themselves?

    Is the APA really not bright enough to see the real future of Collabo-Care?

    I do blame physician members, because unlike taxpayers, they have a choice not to participate.