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

Ref:

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).

More Talk on Psychiatry and the Affordable Care Act

I guess the magical thinking about how a purely political initiative with absolutely no grounding in science will affect the practice of medicine will never cease.  The latest speculation is from the Journal of Clinical Psychiatry and commentary from several prominent psychiatrists (see reference) on "The Effects of the Affordable Care Act (ACA) on the Practice of Psychiatry."  I know I have said this before but there is so much wrong with this piece, it is difficult to know where to start.

The centerpiece like most discussions of the Affordable Care Act focuses in integrated care.  I criticized the American Psychiatric Association for backing any proposal that relegates psychiatry to a peripheral supervisory position looking at so-called measurements to determine if the clinic population is "healthy" or if they need more treatment (translation = antidepressants).  There is weak evidence in this article that this model will be the bonus it promises to be.  Care given in the Department of Veteran's Affairs (VA) clinic is given as example of how things might be.  A patient seeing multiple specialists may receive care from multiple specialists without personally having to coordinate that care.  As a patient at the Mayo Clinic - it has been that way for decades.  In fact, if they know you are from out of town they can frequently coordinate that care on the fly so it can all happen the same day!  No patient aligned care teams necessary there.  Just a good system.

There was a statement about how the ACA could hurt psychiatric care of the seriously mentally ill because the states who previously paid for that care will want to bail out.  The discussants point out "although the ACA plans to reimburse certain institutions for emergency inpatient psychiatric care for Medicaid patients, other evidence based practices for treating severe and persistent mental disorders are not usually covered by health insurance."  Let me translate that for you.  That means there will be even fewer inpatient services.  The inpatient care for mental health and severe addictions takes another hit.  After three decades of decimation by the managed care industry and that same industry shifting the treatment cost for these severe mental disorders to the state - we are going to pretend that nobody needs these services and continue to downsize.  After all, there have been no enlightened managed care CEOs to date who decided that these services were actually important enough to adequately fund.  Why would they now that they have the leverage to shift all of the money to the all important Medical Home?

The idea that physicians will be paid by "value rather than volume" had me laughing out loud.  I pictured the Medical Home psychiatric consultant poring over the clinic's latest batch of PHQ-9 scores and deciding which patient's antidepressants needed tweaking based on this checklist and the cryptic note of a primary care provider.  Will we need more checklists for side effects and unexpected effects on the patient's conscious state?  Will we need checklists for neuroleptic malignant syndrome or serotonin syndrome?  What about the FDA's recent concern about arrhythmias?  Cardiovascular review of systems or electrocardiogram?  That will be a lot of paperwork to look over.  I wonder what the consultant will be paid for delivering that level of "value".   Of course all of the discussants were aware of the fact that most psychiatrists will be employees of some sort or another.  Those who have not been assimilated may be in concierge practices or private practice, but good luck interfacing with the ACO.

The all important technology card was played and how that should cause us all to swoon.  Online or computerized therapy was mentioned.  That modality has been available for over 20 years and not a single insurance company or managed care company has implemented it.  Any cost benefit analysis favors an inexpensive assessment (PHQ-9 + low intensity primary care visit) and even less expensive medications prescribed as quickly as possible.  The unmentioned tragedy of the electronic health record is how much psychiatric assessments have been dumbed down.  The loss of information and intelligence due to the electronic health record is absolutely stunning.  Phenomenological elements that require a substantial narrative or interpretation by a thinking psychiatrist are totally gone.  All that is left is a template of binary elements  that are important only for billing and business purposes.  I suppose the lawyers might like the fact that you check the "Not suicidal" box before a patient is hurriedly discharged.

Psychiatry without a narrative or a formulation or a rationale is not psychiatry at all.  In the end that is what the ACA leaves us with.

George Dawson, MD, DFAPA

Ebert MH, Findling RL, Gelenberg AJ, Kane JM, Nierenberg AA, Tariot PN. The effects of the Affordable Care Act on the practice of psychiatry. J Clin Psychiatry. 2013 Apr;74(4):357-61; quiz 362. doi: 10.4088/JCP.12128co1c. PubMed PMID: 23656840.