A Positive Story for Christmas

I ran across the story posted by Minnesota Public Radio about a psychiatrist retiring in northern Minnesota. The past 30 years or so Dr. Hardwig was the only psychiatrist in International Falls Minnesota. For people not familiar with Minnesota geography I included a map of the state at the top of this post.  It is a town of about 6400 people right on the Canadian border.  It is ranked as the 133^rd largest city in Minnesota. The closest Metro area would be Duluth with a population of about 85,000 people.  International Falls is 163 miles from Duluth and 296 miles from Minneapolis.  As noted in the article, this is a tough place to practice psychiatry. There are few resources and no easily accessible psychiatric beds.

Dr.  Hardwig practiced exclusively in this environment until his recent retirement. In the article we learn that his schedule was always full. He was always willing to fit people into his schedule based on need. He provided a valuable service to this patient’s and primary care physicians in the area. He successfully developed a way to interact with his patients in the community and maintain clear boundaries. He treated the entire spectrum of psychiatric disorders out of necessity. There were no specialists for him to refer to at least in the practical sense. When you advise people that they have to travel 100 or 200 or 300 miles to see a specialist they are willing to do it once or twice but not for the rest of their life.

Full disclosure on my part, I know Dr. Hardwig professionally. He was one of my predecessors as president of the Minnesota Psychiatric Society.  That means over the three years of that professional cycle, he commuted to the Twin Cities and developed agendas, ran meetings, met with MPS members, and conducted all of the other duties of those offices. He was a thoughtful president with a unique perspective also conducted one of our more unique scientific meetings. He also belonged to a discussion group about medicine and psychiatry in that group he talked about his ideas for recruiting psychiatrists into rural areas. That idea was one of the main points of the MPR article.  The shortage of mental health professionals in general and psychiatrists in particular was emphasized. 

This shortage is nothing new. When I started out as a psychiatrist back in the late 1980s, I was assigned to a physician shortage area in northern Wisconsin. I was the only psychiatrist in a county of about 50,000 people for a period of three years. During that time I was the medical director of a community mental health center and for one year commuted to a town 65 miles away to keep their small inpatient psychiatric unit open. They had a deal with the federal government and would lose significant funding if that unit closed down.

One of the early lessons I learned was that I was no longer practicing medicine in a large multi-specialty clinic with unlimited resources.  It is quite a shock to go from an academic psychiatry department with about 60 full-time staff and 24 residents to be the only psychiatrist in town. Professional isolation has been the term used to characterize that situation and also explain why psychiatrists don’t want to wander too far from Metropolitan areas. The atmosphere has improved to some degree with the advent of a functional Internet. While I was in that position, they were trying to get me a telepsychiatry connection through a local hotel satellite television. In the end the cost was exorbitant at about $20K/year and we never tried it.  Today telepsychiatry is routine in the same area and has been used for a decade by the local VA clinic.

The workload was fairly intense at times because our clinic handled all of the crisis calls from the county and I was backup for any nurse, case manager, or psychologist who was doing crisis intervention in the community or in some cases the county jail. There was no cross coverage for vacations or professional conferences.  I was on call 24/7 wherever I was across the country.  On any given night I could find myself seeing somebody in jail, at home, in the small general medical and surgical hospital in town, or any of several nursing homes. But even more pressing was the fact that I was a lightning rod for those people with mental illness and a propensity for violence. All these factors led me to return to a large multi-specialty group at the end of my three-year tenure.

When it comes to figuring out what it takes to be the only psychiatrist in town, treat all possible problems, and do that for decades - I don’t have the answers.  Dr. Hardwig clearly does and by all accounts he did a great job. In my postings of the MPR article in various places around the Internet, I had another psychiatrist question my use of the word “great”. I don’t really see any other way to describe it. What else can you say about the psychiatrist or any physician who practices intensely with minimal support and resources and gets the job done?

There are all kinds of reasons why physicians are critical of one another. There is the competitiveness of youth and the need to secure a position. Most physicians notice that slips away by midcareer and a more important function is teaching and mentoring rather than competing against everyone in the field. Psychiatry is at a disadvantage relative to other medical specialties. The media spin on psychiatry is decidedly negative as I noted in several recent posts. I don’t know if that just gets uncritically accepted or internalized especially by psychiatrists who are criticizing the rest of us. Even though this MPR story was positive it mixed Dr. Hardwig’s career accomplishments with the specter of psychiatrist shortages in rural America. I understand their point, but in terms of motivation focusing on this accomplishment would have potentially done more to motivate people to practice in that environment.  The accomplishments of Dr. Hardwig are certainly inspirational.

I have nothing but the best wishes for Dr. Hardwig in his retirement. Even though there are tens of thousands of psychiatrists to go to work every day and get the job done, his job was probably more demanding with no cross coverage for call or vacations. They have been trying to recruit a replacement ever since he announced he was going to retire and have no success so far. 

I hope they do succeed in finding a psychiatrist as unique as the one who just retired.

George Dawson, MD, DFAPA


References:

Alisa Roth. In International Falls, the last psychiatrist for 100 miles just retired. December 20, 2019. Link.


Graphics Credit:

User: Wikid77 (from National Atlas of the United States) [Public domain]: File URL: https://upload.wikimedia.org/wikipedia/commons/e/ed/Map_of_Minnesota_NA.jpg

A Better Analysis Of The Psychiatrist "Shortage"

A paper in Health Affairs on the "psychiatrist shortage" has been getting a lot of press lately (1).  People are acting like the authors' conclusions are definitive rather than highly speculative, but that is a standard approach in the press.  In the article they use American Medical Association (AMA) Physician Masterfiles from 2003 and 2013 to calculate the number of psychiatrists per 100,000 population for those two dates.  They compare it to similar data for neurologists and family physicians.  Between 2003 and 2013 there was a -0.2% change for psychiatrists as opposed to a +35.7% change for neurologists, a 9.5% change for primary care physicians and a 14.2% change for all physicians in this time period.  They also calculated medians for all groups and coefficients to look at workforce distribution.  As expected psychiatrists and neurologists showed some skew of distribution compared with adult primary care physicians.  That could also be seen in the density of psychiatrists by region:  24.47 per 100,000 in New England to 13.33 per 100,000 in the Pacific area.  They show the geographic distributions by highlighting quartiles of distributions on a quartile map of the United States.  The regions highlighted are 300 - Hospital Referral Regions rather than states.

There appears to be a significant typographical error on page 1275: "Our finding that there was almost a 10 percent decline in the population adjusted mean number of psychiatrists per HHR supports the belief that the supply of psychiatrists likely limits patient access to their services".  They are referring to median numbers here and in their abstract where they use the correct term.  The actual number of psychiatrists in 2003 was 37,968 and in 2013 it was 37,889.  The real numbers just don't seem that dramatic.

In the context of these statistics the authors offer a very inconsistent analysis frequently equating the number of psychiatrists with access to services or imposing severe limitations on treatment as illustrated by their statement: "Since the current supply of psychiatrists is not meeting the needs of people with mental illnesses and is not keeping pace with population growth, policy makers and the medical community must consider ways to address the shortage and improve access to mental health care".  This conclusion is quite a stretch considering data that the authors include in the paper.  They use the figure of 9.6 million adults with severe mental illnesses and only 40% of those people receiving care.  That means if the 37,889 psychiatrists they counted had only 250 people with severe mental illness on their caseload - 100% of these patients would be treated.  I propose that psychiatrists only see patients with the severest forms of mental illness and in today's world 250 patients is a very modest caseload.  In the heyday of psychoanalysis, some analysts did not treat many more patients over the course of their career.   At the maximum this suggests a geographical mismatch between patients and psychiatrists rather than a global shortage of psychiatrists.  Is increasing the supply the best approach to this problem?

In another section of their paper the authors point out that psychiatrists account for only 5% of the mental health workforce; 95% being psychologists, social workers, therapists , and counselors.  They acknowledge that they have no equivalent statistics for those disciplines or nurse practitioners or physician assistants.  Many systems of care these days see a prescriber as a prescriber and selectively hire non-physician prescribers over psychiatrists.  Even without the data it would seem fairly obvious that there has been a proliferation of non physician prescribers over the past decade and no shortage of antipsychotic, antidepressant, stimulant, or benzodiazepine prescriptions.  How can there be a shortage of prescribers in a sea of overprescriptions?

The authors notion that "policy makers and the medical community" are going to provide the solution here is also incorrect on several grounds.  First and foremost - if there is a problem - these are the same people who got us here in the first place.  The authors themselves reference a Graduate Medical Education National Advisory Committee study from 30 years ago predicted the shortage.  Any Medline search looking at "psychiatrist shortage" will also yield papers on this topic dating back to 1979.  In that time frame there have been very modest attempts to expand the workforce in psychiatry.  I made that statement based on expansion of residency slots.  The reality is that there are many International Medical Graduates who are well qualified for residency positions and may have even completed equivalent certifications in their country of origin.  The authors also seem to miss the point that these same "policy makers" have initiated policies to expand non-physician prescribing that has led to decreased staffing by psychiatrists in many settings.  They make the typical mistake that policy makers can't have it both ways and they seem quite intent on reducing rather than expanding the psychiatric workforce.  In the argument the only function a declaration of a psychiatrist shortage limiting mental health treatment is to scapegoat psychiatrists for a problem that may be imaginary but at the minimum is out of their control.  The appeal to policymakers also ignores the fact that policy makers in the US, generally advance pro-business policies that place both physicians and their patients at a distinct disadvantage compared to the business.  I will address some of those points below.

Some additional points not considered by the authors:    

  1.  Inefficiencies in the psychiatric workforce are large - Those inefficiencies are two fold.  First, the practice of psychiatry is notoriously inefficient.  I have done comparisons with both ophthalmology and orthopedic surgery on this blog where comparatively fewer specialists cover an impressive array of serious illnesses.  They do this largely through a much better triage system focused triaging the most serious illnesses.  By comparison, the conditions treated by psychiatrists all receive rationed care and in some cases - the care is completely displaced to a non-medical facility.  In most others there is inadequate infrastructure to address the problem.  The facilities themselves are managed by non-medical administrators who in may cases have caused disruptions in care and severe quality problems.  Care is further fragmented by the fact that managed care companies and governments do not provide realistic reimbursement for the care delivered and incentivize hospitals to provide minimal care.

Second,  managed care and government bureaucrats in their infinite wisdom have made psychiatry even less efficient.  I interject the term "medication management" here as an example and will elaborate below.

2.  The prevailing model of care is antiquated and a throwback to the 1980s - The preferred business and government model of care is the so-called medication management visit also more pejoratively known as the med-check.  It is based on a thoroughly poorly thought out idea that people with severe mental illnesses can be treated with medications for the symptoms of those illnesses.  That model does not work at even the most basic idea that there are social etiologies of symptoms that need to be addressed by social and psychotherapeutic interventions.  There are no medications that treat unemployment, separation and divorce, or the sudden loss of a loved one and yet the entire billing and coding structure for psychiatric visits was based on this model.  Even worse - the productivity scale for employed psychiatrists is still based on this model with a rough correlation between how many people are seen in one day and compensation.

3.   Academic and intellectual approaches to psychiatry are at an all-time low -  An intellectual approach to the field is critical whether considering phenomenology, the conscious state of the individual or all of the medical factors associated with treating the psychiatric disorder.  The environment is also frequently neglected because it is managed by non psychiatrists - at least until there is an incident or violence, aggression, self-injury, or suicide that requires analysis.  The intellectual approach to the field requires study of both the individual and the environment that they are in.  An intellectual approach to psychiatry also requires centers of excellence where people with those problems can go to receive expert care.  Centers of excellence are much less common in psychiatry than other fields.  Over the past 20 years academics and educators in the field have been subjected to the same productivity demands as clinicians.  Academic work of all kinds is devalued in order to increase the number of  patients visits focused on medications.  All incentives in place from the policy makers point toward a continued non-intellectual approach to the field.

4.  Practically all employer based positions are burn-out jobs - Reasonable people will work them for a time and then quit and ask themselves how they got involved in that situation in the first place.  The authors seem to think that better compensation or collaborative care models would increase the participation of psychiatrists in these flawed systems of care where they are "supervised" by unqualified business people.  To me the best insurance against burnout and practicing a higher standard of care is to not accept any payment arrangement that involves your work or professionalism being compromised.

5.  Public health and infrastructure needs are always neglected when it comes to psychiatry and mental health -  The most pressing issue is the dismantling of hospital structures and hospitals with therapeutic environments.  We cannot expect this to be rebuilt with the current paradigm of containment and maximizing profit by discharging people without adequate treatment.  Another way to look at the situation is that we cannot expect intellectually stimulating, state-of-the-art treatment environments when the only admission criteria is business and government defined dangerousness.  We also need therapeutic environments for the psychiatrically disabled rather than psychiatric slums and homelessness.

 The public health measures do not stop there.  America's huge appetite for addictive drugs drives a lot of psychiatric morbidity.  This offers one of the best areas for reducing the incidence of psychiatric problems and the need to see a psychiatrist.  Nobody at the policy level seems to be very interested in this problem.  Perhaps it is a resignation to the political success of the cannabis movement and more recent ideas about psychedelics being therapeutic drugs.  Reducing drug addiction and exposure would not only reduce the incidence of accidental overdoses but it would also reduce the incidence and severity of psychiatric disorders by an additional 30%.  Addictive drugs is just one aspect of prevention that is ignored by policy makers.  I would list violence and homicide prevention as a close second.

I still operate from the basic assumption that physicians are bright, well intentioned people.  That means they operate best when they have a manageable schedule, are not overworked and sleep deprived, and are allowed time for intellectual pursuits in their field.  You don't go into medicine to put in 8 hours, punch a clock and go home.  Ideally there is intellectual stimulation at work every day.  The intellectual stimulation certainly needs to be there if the psychiatrist has any involvement in teaching psychiatric residents.  It can't be there if physicians are managed like production workers especially when the product they are producing is an inferior one.

And practically every psychiatrist knows that the business-managed work product that they produce is markedly inferior to what they were trained to do and what they are capable of.  That is what fuels the private practice movement - NOT financial remuneration.

How can anyone expect to recruit and retain psychiatrists when their practice environment is actively being destroyed?  Why would anyone be interested in the field?



George Dawson, MD, DFAPA



1: Bishop TF, Seirup JK, Pincus HA, Ross JS. Population Of US Practicing Psychiatrists Declined, 2003-13, Which May Help Explain Poor Access To Mental Health Care. Health Aff (Millwood). 2016 Jul 1;35(7):1271-7. doi: 10.1377/hlthaff.2015.1643. PubMed PMID: 27385244.

Lessons From Orthopedic Surgeons

I sprained my ankle last Friday.  It was a curious experience because it is probably the first time I sprained an ankle in about 40 years.  I just rolled it over coming off the bottom step of a stairway and then did the same thing at home the same day.  Some pain but not bad.  I was immediately able to walk on it and bear full weight on it.  Over the next week it was a waxing and waning course.  Still able to walk.  Most of the stiffness and pain in the morning.  About every other day I took a tablet of the naproxen in the morning and that seemed to alleviate the pain by evening.  I went to work, at a job where I typically put in at least 10,000 steps per day on a fairly large campus.  A week later it was unchanged, still painful at times and swollen.  I thought I needed an x-ray to rule out a fracture.  The question is - where to go?  Emergency departments in my experience are the absolute slowest.  I could also imagine the eye rolling when I tell them the injury is a week old.  I could go to the local urgent care center, but they seem surprisingly ill equipped for most problems.  I was there a few years ago for bronchitis and they shot a chest x-ray that was overpenetrated and useless for seeing infiltrates.  I would not have  lot of confidence in their ability to shoot an ankle film with adequate technique to take an optimal look for fracture sites.  I could go to my primary care  clinic, but that takes phone time and half a day of PTO.  All I need to know - is there a fracture, do I need to see an orthopedic surgeon, and what do I do to take care of it.  The last time I had an orthopedic problem and needed to get a splint, my primary care clinic referred me to a pharmacy that had a lot of medical equipment.  They did not have much in onsite to help me.

Then I remembered seeing an ad for an orthopedic surgery specialty group.  They had a number of new city-wide clinics.  One of their features was an acute injury walk in clinic.  No appointment was necessary.  I had nothing to lose.

The clinic lobby looked like one that you might see in a luxury hotel.  There were a bank of receptionists there to get the process going.  After about 10 minutes of paperwork, I was taken to an exam room by an RN who examined the ankle and took additional history.  A minute later, I was off to x-ray for three views of the ankle.  A minute after I got back to the room, I was examined by a physician's assistant who immediately let me know that there was no sign of a fracture.  She took additional history, and did a more extensive examination of the foot and ankle.  he showed me very good resolution views of the ankle on her flat screen computer monitor.  She Ace wrapped the ankle gave me some care advice, two extra Ace wraps and sent me on my way.  The total time of the visit was 30 minutes - 20 minutes if you don't count the time I was filling out the forms.  It was all very focused and very efficient.

According to the American Academy of Orthopaedic Surgeons, in 2014 here were 28,047 orthopedic surgeons in the United States.  The American Association of Medical Colleges estimates 49,079 psychiatrists for  comparable time period (2013) in the US.  Various sources including the American Psychiatric Association release stories about the shortage of psychiatrists.  I have not ever heard of a shortage of orthopedic surgeons.  But what does that mean?  Shortages are often measured by the ease of getting an appointment.  In some cases managed care organizations are quick to point this out possibly because many psychiatrists have fled both their work environments and compensation schemes.  The collaborative care models (there are several) are a work around in that patients can continue to go to their primary care clinics where there is a psychiatrist working behind the scenes - assuring that their medication therapy is rational and that their rating scale scores are trending in the right direction.  As far as I can tell, the vast majority of patients in collaborative care will never see a psychiatrist.  Problem solved right?    

Nobody seems to be applying the model I just experienced in this very focused and efficient orthopedic clinic.  The principles that I directly observed are:

1.  Not everybody needs to see a psychiatrist - The criteria for seeing a psychiatrist are very subjective based almost entirely on what the patient or the psychiatrist wants.  Many private practice psychiatrists want a set period of time to do an initial evaluation and follow ups.  Employed psychiatrists have to use whatever time they are allotted by the masterminds who are managing their productivity.  What is the lesson from the orthopods?  Triage the patient and see only the patients with the most complex problems.  As long as I did not have a complex ankle fracture, I could see a PA-C and get perfectly fine care.

2.  The resulting structure of the clinic benefits from that hierarchy of complexity - There were numerous exam rooms with teams of PA-Cs, nurses, and x-ray techs, screening high numbers of walk ins and treating them rapidly and efficiently.  The orthopods were on site doing ambulatory surgery and following up with complex post-op and non-operative patients.  There were also a number of physicians on site who were not surgeons but who focused on the medical treatment of sports injuries and spinal problems.  This has immediate applicability for psychiatry.  The procedures in psychiatry that create bottlenecks are electroconvulsive therapy and more recently ketamine infusions and transcranial magnetic stimulation (TMS).  Shifting psychiatrists away from more routine problems would immediately create greater capacity within systems to offer that higher level of care and it could be delivered in an ambulatory setting.  It could potentially provide needed treatment to thousands of people with treatment resistant problems who do not have easy access to a more intensive level of care.

3.  The culture of the orthopedic clinic was the care of the orthopedic patient, greatly enhancing the efficiency and focus of that process.  Orthopods don't provide collaborative care in primary care clinics and there is no broad initiative to get them there. Specialization has its benefits and in my experience all of the clinic personnel being focused on orthopedic problems was a plus.

4.  The orthopedic clinic had certain expectations of social behavior - it was not explicit but you needed insurance or an ability to pay.  Everyone was well behaved and nobody there was agitated or angry.  That may sound elitist, but for many mental health and addiction clinics there seems like an expectation that any behavior is tolerated and if the staff has to expend considerable time and effort to deal with the complex problem of aggression or agitated and otherwise inappropriate social behavior - they should also be prepared to provide those hours of care for free.

5.  The orthopedic clinic was providing care that has traditionally been done in hospitals and they were quick to point out the differences - complex care being delivered in a setting in  comfortable non-hospital surroundings with staffing ratio high enough to provide the level of care that people expect.  Managed care hospitals and clinics often try to manage expectations by interviewing protocols prior to giving that patient a satisfaction survey.  The approach used in this clinic is to redesign the clinic and service delivery first and then see what happens on the surveys.

6.  The orthopedic clinic has state-of-the-art equipment - No x-ray machines from the 1980s.  I saw high resolution images a few minutes after they were taken on a computer monitor in an exam room.  The contrast was excellent.

I know that a lot of physicians reading this are thinking that I have lost it.  Orthopedic surgery is a much more well compensated and well defined field than psychiatry.  How would a group of psychiatrists attempting this model be able to pull it off financially?  The biggest risk of course is managed care companies shifting most if not all financial risk to the clinic and poor reimbursement from public payers.  In my opinion, a lot of that is because of the usual biases against psychiatric care, but it is also due to the lack of negotiating savvy on the part of psychiatric clinics.  There is also a well known bias by managed care companies to get rid of psychiatric services or ration them either out of existence or to the point that any psychiatrist working for them is assured of providing a lot of work for free.  A good place to start would be to study models like this one or radiology or anesthesiology groups and figure out what percentage of their customary fees do they negotiate for in contracting arrangements.  Without that knowledge - you can't keep your doors open unless you adopt a straight fee-for-service arrangement with cash paying customers.  It has been demonstrated time and time again that managed care companies shut down psychiatric clinics and reimburse so poorly that most practitioners cannot accept their patients.

There are a number of arguments out there - many by other psychiatrists on whether a clinic like the one I suggest should exist.  The standard argument is that it will skim off the "worried well" and not treat serious psychiatric problems.  My experience in numerous clinics and hospital settings would suggest otherwise.  There are many people with acute crisis situations or stress responses who end up in the emergency department where they get admitted on emergency involuntary holds.  They may go to a primary care clinic where they are referred to the ED if they are perceived as having suicidal ideation or just put on antidepressants.  The majority of these patients do not have a serious psychiatric disorder and need a crisis care center where they can get active treatment.  In this case the "worried well" have been mishandled for decades.  Another resource that is needed is a safe place to treat hypomanic or manic patients who can't function at work or at home.  None of these folks likes to be housed in a hospital active day treatment with some temporary housing may be possible in a large well resourced psychiatric clinic.

Psychiatry has been thoroughly fragmented by by managed care systems and governments.  A large clinic like the orthopedic clinic I described, but focused on psychiatric services could potentially pull together many of the resources needed for comprehensive care and greatly improve quality.  Anything moving psychiatric practice away from brief sessions focused on managing polypharmacy toward providing comprehensive services again would do the same.


George Dawson, MD, DFAPA



Attributions:

1.  Left ankle is my actual ankle x-ray.

Blaming Psychiatrists For Decreased Access - The Ultimate Political Manipulation?

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 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.    

Supplementary 2:  A reader suggested that I was erroneously saying that managed care hit mental health services harder than the rest of medicine.  The following excerpt from a report by Floyd Anderson, MD describes the results of the Hay Group report on this issue in the 1990s:

"More recently, the National Association Of Psychiatric Health Systems - Hay Group found that from 1988 to 1997 that a total value of health care benefits for over 1,000 large U.S. employers declined by 10%; general health care benefits declined by 7%, but behavioral health benefits declined by 54%. As a proportion of total health benefit costs, behavioral health benefits decreased from 6% to 3% during that period. This same study found that between 1993 and 1996, the use of outpatient behavioral health services dropped 25%, but use of outpatient general health services increased 27%. Inpatient psychiatric admissions between 1991 and 1996 declined by 36%, compared with a 13% decline for general health admissions during that same period. Mental Health Economics reported in September of 1999, “Despite the robust economy of the past five years, and the growing awareness of disparity between mental health care benefits and general health care coverage, the value of employer-provided mental health care benefits has declined by over 50% since 1988.”

That occurred in the context of overall health care expenses increasing. And do you really need a report? It may be hard to believe, but mental health services were delivered outside of jails at one point in time.