How Can Psychiatry Save Itself?

The front page article of the Psychiatric Times is Ronald Pies article: “How can American Psychiatry save itself?”  The only thing more excruciating than watching a well written article stretched across 7 pages of drug ads is the rehashing of what are essentially political arguments against the field.

DSM 5 – good or bad?  Lack of objective markers, lack of a biological basis of behavior or an adequate description of the phenomenology, yada, yada, yada.

The articles about a $3.5 billion shortfall in funding state mental health programs and the elimination of psychiatric services at Cedars-Sinai stand in contrast to the science and philosophy of what is wrong with psychiatry.

Ever since I became a psychiatrist, I have been impressed with the levels of self flagellation in the field.  Psychiatrists will provide any number of debates about what is wrong with the field and in the more extreme cases agree with any scapegoating of the field based on the behavior of a few.  We also seem to have the largest number of experts who want to make a living out of critiquing the field.

A good comparison would be with our colleagues in Cardiology.  There is currently a boom in implantable pacemakers and implantable cardioverter defibrillator devices (ICDs).  The widespread use of many of these devices is at least as controversial as anything in the field of psychiatry and yet compared with the 2100 hits that Dr. Pies got when he Googled “psychiatry is in trouble” – I got NOTHING for “cardiology is in trouble”.  I can go on to pulmonary vein isolation by either radiofreqency or cryosurgical ablation for paroxysmal atrial fibrillation as controversial measure number 2.  It would not stand the scrutiny that the FDA gives antidepressant drugs.  And yet while psychiatrists are ridiculed for using antidepressant drugs, nobody blinks an eye as hundreds of thousands of afibbers get ablation procedures every year despite the fact that reviews describe a 20-30% immediate recurrence rate and a long term recurrence rate of 9% per year.  There have also been no commentaries on the fact that nobody knows what an ablated left atrium looks or functions like 10 – 20 years down the road.

I generally like what Dr. Pies writes.  I like his incorporation of philosophy in his articles.  I like the way he refutes the common rhetoric used against us.   I am awaiting his suggested solution in the second article in this series and hope he has concrete suggestion to refute the rhetoric against us and expose the fallacy that there is more wrong with psychiatry than there is  with Cardiology – even though the Cardiologists have all the procedures and they tend to get paid for their work.

But let's face it - psychiatry's longstanding obsessions about whether or not we measure up to the rest of medicine should have been put to rest a long time ago.  That was when we became and still are the last hope for large groups of people with severe mental illnesses.  Our record of improved treatment in this group of patients ranks with the best treatment achievements in medicine.

Why I don't use the term "Behavioral Health"

It was obvious to me from day one that this was a business strategy.  When I worked in a hospital I wore a standard white coat and embroidered under my name was the word PSYCHIATRY.  I was after all a board certified psychiatrist and every other doctor in the place had their specialty under their name.  One day back in the early 1990s, my boss summoned me into his office and said that were were going to replace PSYCHIATRY with BEHAVIORAL HEALTH.  After all we did not want to alienate the non psychiatrists working in the department who work on our teams.

Something about that explanation did not add up.  The other specialists also worked on teams and did not change the name of their specialty to match  the function of the team.  Besides the term MENTAL HEALTH was a perfectly respectable term that all of us had worked under for decades.  What was the push for BEHAVIORAL HEALTH?

Now we all know that it was part of a business strategy to marginalize professionals and make it seem like a business strategy was somehow good for mental health and psychiatric treatment.

I told my boss that if I was board-certified in behavioral health it might make sense, but barring that I would stick to PSYCHIATRY.  He agreed but over the years that followed the term BEHAVIORAL HEALTH has penetrated the marketplace even in the public sector.  More importantly the associated management strategies have led to rationed care and access to care as well as lower quality of care for all person with mental health problems.

There has been some movement toward renaming BEHAVIORAL HEALTH UNITS to MENTAL HEALTH UNITS.  But I haven't seen that in the Twin Cities or Midwest yet.

Financial Marginalization of Psychiatry

I wrote this original article in 2005 for the Minnesota Psychiatric Society newsletter in response to two developments.  First, it is one of the only articles that you will ever see quoting actual prices in terms of bills and what the actual reimbursement is.  Contrary to the myth of expensive health care, I have had people tell me how shocked they were at how little of a bill the insurance company actually paid.  The author here gives the actual dollar amounts.  Second, there is an obvious boom in Cardiology services at a time when psychiatric services were being strictly rationed according to managed care "carve out techniques." At the  time this article was originally written 100,000 patients per year received implantable cardioverter devices (ICDs) at a cost of $2 billion and a pulse generator replacement cost of an additional $1.4 billion.  Using the figures from this article that is the equivalent of 794,000 psychiatric hospitalizations per year.  The original article and the reference begins with the paragraph below.

A recent Twin Cities article on the escalation of technology and real costs for cardiac care in Minnesota highlighted just how severe the resources have been skewed away from psychiatric care. If you have been following the Minnesota Psychiatric Society's initiatives in this area over the past few years it will probably come as no surprise - but even in that context I found the following numbers somewhat shocking:

1. Minnesota (a state with maximal managed care penetration) - has 40% fewer mental health beds per capita than the nation.

2. In the past 5 years - 5 new cardiac care facilities have opened at a cost of $263 million.

3. An analysis of Medicare cost data for one hospital (United) shows why cardiac care is expanding and psychiatric care is shrinking. Here is a direct quote from the article:

"A look at Medicare cost data for one local hospital shows why. It cost United Hospital $8,091 to implant a pacemaker, but the hospital received $11, 538 for each procedure, according to 2003 data provided by the American Hospital Directory.

On the other hand, it cost United $10, 132 to treat a patient with psychosis, but the hospital received only $4, 282 per case. These are federal Medicare figures but the same disparities exist in payments by private health plans."

That's why you are seeing all of those shiny new Heart centers and no new psychiatric hospitals. Combined with the psychiatric outpatient penalty - it probably also goes a way toward explaining why the system is so fragmented and the seriously ill cannot find a psychiatrist.  Also notice that the insurers were described as worried about how to contain Cardiology costs, but the reality here is that all of these Cardiology services are owned by the major managed care companies.

George Dawson, MD

Hauser RG.  The growing mismatch between patient longevity and the service life of implantable cardioverter-defibrillators.  Journal of American College of Cardiology 2005; 45 2022-5.

Olson J. Cardiac care focus worries insurers. Pioneer Press, August 8, 2005: p 1A, 4A

Knowledge Workers

Imagine working in an environment that is optimized for physicians. There are no obstacles to providing care for your patients. You receive adequate decision-support. Your work is valued and you are part of the team that gets you immediate support if you encounter problems outside of your expertise.  In the optimized environment you feel that you are working at a level consistent with your training and current capacity. That environment allows you to focus on your diagnosis and treatment of the patient with minimal time needed for documentation and coding and no time wasted responding to insurance companies and pharmacy benefit managers.

As I think about the problems we all encounter in our work environment on a daily basis I had the recent  thought that this is really a management problem.  Most of the management that physicians encounter is strictly focused on their so-called productivity.  That in turn is based on an RVU system that really has no research evidence and is clearly a political instrument used to adjust the global budget for physicians.   Current state-of-the-art management for physicians generally involves a manager telling them that they need to generate more RVUs every year.  Managers will also generally design benefits and salary packages that are competitive in order to reduce physician loss, but this is always in the larger context of increasing RVU productivity.   Internet searches on the subject of physician management generally bring back diverse topics like "problem doctors", “managing physician performance”, "disruptive behavior", “anger management”, and “alcoholism”, but nothing about a management plan that would be mutually beneficial for physicians, their patients and the businesses they work for.

In my research about employee management I encountered the work of the late Peter Drucker in the Harvard Business Review.  Drucker was widely recognized as a management guru with insights into how to manage personnel and information going into the 21st century. One of his key concepts was that of the "knowledge worker".   He discussed the evolution of managing workers from a time where the manager had typically worked all the jobs he was supervising and work output was more typically measured in quantity rather than quality. By contrast knowledge workers will generally know much more about their work than the manager.   Work quality is more characteristic than quantity.   Knowledge workers typically are the major asset of the corporation and attracting and retaining them is a corporate goal.   Physicians are clearly knowledge workers but they are currently being managed like production workers.

The mistakes made in managing physicians in general and psychiatrists in particular are too numerous to outline in this essay. The current payers and companies managing physicians have erected barriers to their physician-knowledge workers rather than optimizing their work environments. The end result has been an environment that actually restricts access to the most highly trained knowledge workers.   It does not take an expert in management to realize that this is not an efficient way to run a knowledge based business.   Would you restrict access to engineers and architects who are working on projects that could be best accomplished by those disciplines?   Would you replace the engineers and architects by general contractors or laborers?   I see this dynamic occurring constantly across clinical settings in Minnesota and it applies to any model that reduces psychiatric care to prescribing a limited formulary of drugs.

I think that there are basically three solutions.   The first is a partial but necessary step and that is telling everyone we know that we have been mismanaged and this is a real source of the so-called shortage of psychiatrists.  The second approach is addressing the issue of RVU based pay directly.   I will address the commonly used 90862 or medication management code.  As far as I can tell people completing this code generally fill out a limited template of information, ask about medication side effects, and record the patient's description of where they are in the longitudinal course of their symptoms and side effects.  Many managed care companies will ONLY reimburse psychiatrists for this stripped down intervention.    I would suggest that adding an AIMS evaluation or screen for metabolic syndrome, an in-depth probe into their current nonpsychiatric medications and how they interact with their current therapy, adding a brief psychotherapeutic intervention, case management discussions with other providers or family, and certainly any new acute medical or psychiatric problems addressed are all à la cart items that need to be assigned RVU status and added to the basic code.   Although there are more, these are just a few areas where psychiatrists add quality care to the prescription of medicines and managed care companies do not.  The final solution looks ahead to the future and the psychiatrist role in the medical home approach to integrated care. We currently have to decide where we fit in that model and make sure that we don't end up getting paid on an RVU basis while we are providing hours of consultation to primary care physicians every day.

Overall these are political problems at the legislative, bureaucratic and business levels.  It should be apparent to anyone in practice that when political pressure succeeds in dumbing down your profession – it necessarily impacts adversely on your work environment, compensation, and most importantly your ability to deliver quality care. 

Why This Blog?

I thought that a blog written by a psychiatrist who has no stake in bashing psychiatry and who has successfully treated patients for over two decades is long overdue. In the absurd world of today's media and their completely unrealistic portrayal of psychiatry and psychiatrists, political arguments can be advanced against the field and that leads to a rapid acceleration of bashing of the field fueled by others who frequently don't know a thing about psychiatry. I plan to post a few examples in the days that follow about that process and also about the political motivations for that process.

I also do not want to set myself up as a guru or somebody who is unique. That is often the viewpoint taken by critics of the field. At this point in my career, I personally know hundreds of technically competent psychiatrists who are every bit as skilled as me. In fact, I like to provide the example of a patient who came to see me for geriatric consultation. At the end of the visit she produced a previous evaluation from a colleague who trained with me at the University of Minnesota. That note right down to the diagnostic evaluation and plan was identical to what I had in my handwritten notes to that point.

Finally, the viewpoints expressed here are probably not mainstream psychiatry. Psychiatrists in general like to avoid conflict and attempt to resolve problems in a non confrontational manner. Physicians in general seem to ascribe to this tactic. While I agree completely that it is necessary to be neutral in all interactions at a clinical level, that does not extend to politics - especially in an era where an activist government and a managed care cartel are restricting psychiatric care at a much higher rate than they are restricting access to medical and surgical care.

What follows here is strictly my opinion and not the opinion of any of my current or past employers or of my professional associates.