Saturday, March 05, 2011

Talk Doesn't Come Cheap



Gardiner Harris has an article in today's New York Times called "Talk Doesn't Pay So Psychiatrists Turn to Drug Therapy." The article is a twist on an old Shrink Rap topic--Why your Shrink Doesn't Take Your Insurance. Only in this article, the shrink does take your insurance, he just doesn't talk to you.

With his life and second marriage falling apart, the man said he needed help. But the psychiatrist, Dr. Donald Levin, stopped him and said: “Hold it. I’m not your therapist. I could adjust your medications, but I don’t think that’s appropriate.”

Ah, Dr. Levin sees 40 patients a day. And the doc is 68 years old. This guy is amazing, there is no way I could see 40 patients a day for even one day. He's worried about his retirement, but I wouldn't make it to retirement at that pace. Should we take a bet on whether Dr. Levin has a blog?

So the article has a whimsical, oh-but-for-the-good-old-days tone. In-and-out psychiatry based on prescribing medications for psychiatric disorders is bad, but the article doesn't say why. In the vignettes, the patients get better and they like the psychiatrist. Maybe medications work and psychotherapy was over-emphasized in the days of old? The patients don't complain of being short-changed, and if Dr. Levin can get 40 patients a day better for ---your guess is as good as mine, but let's say-- $60 a pop and they only have to come every one to three months, and there's a shortage of psychiatrists, then what's the problem? Why in the world would anyone pay to have regular psychotherapy sessions with the likes of someone like me?

After my post last week about The Patient Who Didn't Like the Doc. On Line , I'm a bit skeptical about on-line reviews. Still, I Googled the psychiatrist in the story, and the on-line reviews are not as uniformly positive as those given by the patients who spoke to Mr. Harris. Some were scathing, and they complained about how little time he spends with them. In all fairness, others were glowing.

The article makes psychiatrists sound like money-hungry, unfeeling, uncaring, sociopaths. Either they're charging $600 a session (...oh, can I have that job?) or the financial aspect is so important that they're completely compromising their values for the sake of a buck. This doctor believes that patients get the best care when they receive psychotherapy, and the rendition Mr. Harris gives is that it's understandable that he's compromised his values to maintain a certain income. I don't buy it and I don't think it portrays psychiatrists accurately or favorably. If the doctor felt that it was the high ground to give treatment to 40 patients a day who otherwise couldn't get care, then this portrayal wouldn't be so bad. And that may be the case---I don't know him and I don't know Mr. Harris and I do know that an occasional reporter has been known to slant a story. I found it odd that there were no other options here aside from 4 patients/hour, 10 hours/day, not to mention the 20 emergency phone calls a day that he manages in the midst of all the chaos. Why hasn't this doctor left the insurance networks and gone to a fee-for-service model with a low volume practice if psychotherapy is what he enjoys and what he feels is best? Or why doesn't he devote an hour or two a day to psychotherapy? Okay, I shouldn't rag on the poor doc, I only know him through a newspaper portrayal, but I don't think this article showed psychiatry at its finest hour. And yes, I know there are psychiatrists out there who have very high volume practices.

39 comments:

Anonymous said...

My psychiatrist sees 35-40 patients a day, as well. I feel like a widget on a prescription-writing assembly line. He doesn't like it when I tell him this. Oh well. How I feel is how I feel.

I think it's egregious that a *psychiatrist* would see 40 patients a day. They cannot possibly do their jobs well that way - I'm sure many of them tell themselves they're doing a good job, but give me a break!

I definitely feel like a number and I definitely feel like he's a drug dealer. I also feel like he's completely detached emotionally. In turn, that makes me feel resentful which then leads me to become detached. It's reached the point where I sit down, spit out the facts about mood, sleep, concentration, etc. in a "name, rank and number" fashion, wait for his "wise" suggestions and then leave. I'm doing my part to keep his assembly line running on-time.

I will also say that I often do not take his advice about medication changes because it seems ridiculous to me that someone would make changes to my drugs based on a 10 minute meeting that occurs every couple of months. I just don't value that input very much because I can't really take it seriously. Medical training aside, I find it laughable that he thinks he can get a reasonable assessment of how I'm doing when he spends a grand total of 1-1.5 hours per year with me.

Quite literally *all* of my other doctors spend more time with me and show more concern for my psychosocial health than my psychiatrist does - and that is a sad, ironic truth.

I don't see a lot of skill involved in running through a few medication classes in your head and then scribbling one of the meds on a prescription pad. If I had gone to med school, I would feel ashamed to practice that way. What a waste of a long, difficult and expensive (as they so like to remind us) education.

moviedoc said...

40/day would be too many for me, and Dr L should get a blog. But it isn't just the money. You don't need an MD to do psychotherapy well, and I believe the people who focus on pharmacotherapy do it better than those who try to be psychotherapists too. (I call them sporkiatrists.)

Sarebear said...

My charge for my psychiatrist is $80 bucks a pop and that's for a 20 minute appointment, so she sees three people an hour. I don't know if she does any psychotherapy hours or half-hours, but I suspect not. She tends to do a sort of mini-therapy in our time together, along with the med stuff. This is how much she got back when I was on insurance, too.

Oh, I currently see her once a month, since we're trying to find effective medication for various things.

In comparison, my insurance only ever paid my psychotherapist $70 for the 50 minutes of psychotherapy; gee, $80 for 20 mins or $70 for 50 minutes, that doesn't seem fair, does it? Not that you were asking, but since you didn't have any idea on the iatrist fee I thought I'd say.

Anonymous said...

that is why I have the psychiatrist for the meds and a Psychologist for the talk therapy. Good thing they communicate.

Jude said...

In the old days when I saw psychiatrists, I only met with two. When I started to tell one about my problem, he said, "There are plenty of other people you can tell your problems to--we only have a few minutes. What drugs have you tried?" The second,who saw my once a month, didn't seem to notice when I stopped going. A year later, I received a notice that she was moving, and I thought, well, that's nice, but I went off drugs a year ago. Silly psychiatrists. That second one actually did notice that I have anxiety and she encouraged me to have my deviated septum operated on, so she wasn't a total waste of time--oh, yeah, and she gave me lots of free drug samples, which made up for the fact that I couldn't afford to see her, let alone purchase the drug prescriptions.

Deneb said...

I feel really lucky to have my psychiatrist. I live in Canada so I don't have to worry about paying for sessions. It's already paid for by taxes.

I've seen her for almost 10 years now. I started seeing her when I started university. I see her twice a month now. There was about a year when I saw her every week.

She prescribes my meds and also gives psychotheraphy. She really knows me very well after 10 years of twice a month or 4 times a month sessions of 15 to 45 mins length.

I know she cares about me and I feel cared about.

I've improved SO much in these years. According to her I no longer meet criteria for borderline personality.

I would be so lost without her. Talk is definitely not cheap. I know it must cost a lot, but it has helped me so much. The meds, the caring, the psychotherapy, it was all essential to my recovery.

I am putting my life back together now and I'm happy despite things not being perfect.

I just love life so much now and my psychiatrist played a major role in my coming to this point in life!

There are GREAT psychiatrists out there. I think they can be good with both meds and psychotherapy. :-)

Anonymous said...

I am speechless that someone who calls himself a doctor would blow off a patient who said he started drinking again among other things. Did it not occur to Dr. Levin that drinking while taking meds doesn't usually lead to a good result? Of course, we don't know how much the patient was drinking but when he mentioned he started doing this, since he is also taking meds, it is an MDs job to explore this further. To punt this off to a therapist is a dereliction of duty in my opinion.

moviedoc said...

Agree with Anon: alcohol interacts with other CNS drugs. The psychiatrist should address. Sarebear's psychiatrist's "mini-therapy" not only helps patients, but when I do it I get valuable info that helps me do a better job. And as I've said before, non-psychiatric physicians would do well to learn the skill too.

Anonymous said...

Telling a patient who is talking about his problems, "Stop... that's not appropriate" is completely inappropriate. This guy sounds like a complete greedy jerk. He should go back to working his other gig and get out of private practice. By doing a half-as*** job, he's surely harming some patients. Better just not to practice at all... but money seems very important to him.

Anonymous said...

I'm getting very tired of hearing people who make at minimum 4x what I do whine about money and use the "not getting paid enough" argument to justify doing a half-assed job.

I get shuffled in and out the door every one to three months by a doc who then charges me extra to talk to any of my other docs or do anything outside of a "are you still alive" appt.

Why should it be any surprise to any of my docs that I am angry about my chronic illnesses? They are the ones that seem to use my chronic illnesses as an ongoing revenue stream of followup but dont listen or help appts that take me away from work, pay them and help me none.

Anonymous said...

I didn't take the NY Times article as whining about money. It sounded to me like someone who failed to save for retirement and is now doing what he can, even if he doesn't like it, to make up for that, in a way that allows him to continue taking insurance. The article said he could easily charge 600 an hour and not take insurance (although I do question that number since my manhattan shrink charges 350/45 mins and does not take insurance). I don't think anyone believes the system is ideal, but I see no reason to turn this into a debate about the (allegedly) haves and the haves not as much. Don't we get enough of that in the news media?

Anonymous said...

It's long been clear to me that the best situation would be for insurances to reimburse physicians enough to make it feasible (and I'm talking realistically, comparable to any other medical specialty - ie, the appointments I have with a neurologist, OB/GYN, etc are typically 40-50 minutes, too) for them to accept insurance....thus leaving me paying the same copay I pay to anyone else, not the $200/hour I pay now.

That said, the thing that surprised me most about the article was that he came out of it looking like an ass. I don't feel bad for him at all.

Anonymous said...

re 2 down

if your mind is exerting that much energy, isn't it your god given right to be sucking some1 in.

If you can access a cooking shows photos, then I don't see any reason why you can't get your hands on some bloody fight gear.

write?

:0)

DIY Health said...

I just pray that more psychiatrists will get to practice this year so that the fees would lower down because of competition and so that no more patients will fall in line for hours just to be entertained for 15 minutes. My uncle had schizophrenia and I'm glad that his doctor was so patient to him and he had a sister-in-law who was a nurse.

jesse said...

Psychiatry has always had practitioners who were much more interested in physical medicine than in psychology, and vice versa, but the field has indeed changed. There used to be much more of an awareness that the physical and emotional aspects of human beings were intricately entwined, and in fact that a division was artificial. In that view the best treatment for many patients came from an understanding of both the mind and the body, of behavior and chemistry. Emotions, memories, experiences influenced chemistry, and chemistry would drive emotions.

For some patients perfecting the chemistry is all-important, for others the psychology, and for many compromise between the two is best, but how and by whom is this to be determined?

jesse said...

Gardiner Harris's article forces us to look at a very unpleasant truth: Psychiatry has changed dramatically over the last twenty years and much of the change has been precipitated, not by research or the advent of new medications such as Prozac, but by managed care reimbursement policies.

When Irv Cohen of Sheppard Pratt wrote 35 years ago that "philosophy follows funding" he meant that not just the surface action, but the very core of what we believe, is shaped by economic forces.

The key to the NYT article is not in the description of Dr. Levin, but in the title: Talk doesn't Pay, so Psychiatry Turns Instead to Drug Therapy. While there have always been debates between those who pay more attention to the biochemistry and those more taken by the psychology, no field in medicine has been so shaped by managed care as to be completely transformed by it. This is the reason, I would surmise, that Mr. Harris began his series with psychiatry.

Dinah said...

Managed care and poor reimbursement have certainly shifted practice so that insurance-based practitioners can no longer make a living doing psychotherapy (in combo with meds, sporkiatrist style). It's a real problem, and Gardiner Harris had the opportunity to highlight this problem in a way that would grab people's attention and perhaps effect change. Instead, his portrayal is of someone who comes off an uncaring and money-grubbing. (And I don't know if this is an accurate portrayal or a picture that has been painted. If I were Dr. Levin, I'd be hiding in a cave today). I'm a psychiatrist, I understand the economic forces, and they are a problem, but I read this article and had no sympathy for this story. The journalist couldn't have chosen a psychiatrist with 250K in educational loans and 3 children? Instead, he picks a guy who has completely compromised both his own values and patient care in order to squeeze out roughly $2000 (if not significantly more) a day in income because the stock market drop might impact his ability to maintain a specific lifestyle? Perhaps there is something more that we didn't hear about driving him-- enormous medical bills, some personal fiasco-- but if those were part of the story then they weren't related. Did Mr. Harris search for the most unsympathetic shrink he could find to make the point that psychiatrists are greedy?
Some psychiatrists are greedy and don't care about their patients.
It's fine if you don't lump the Shrink Rappers in that group.

Anonymous said...

yikes! now your a fricken Dr! LOL!

say your little name! mr claw! and his dancing talking parrot jeff! carrying a very overloaded MBA! LOL!

moviedoc said...

I think you're unnecessarily defense, Dinah. Haven't you said before each of us has a right to choose how to practice? We all make compromises. God knows signing one of those insurance contracts is a compromise. I suspect he's providing decent care to a lot of people. Nobody forces them to go to him. Journalists don't have to be objective.

moviedoc said...

I meant defensive.

And think how many patients read that article and ask, "Why don't those patients just go to their primary care once a year for their meds?"

Anonymous said...

350 for 45 minutes is about a dollar thirty per SECOND.

Anonymous said...

Insurance pays my psychiatrist $100 for a 15 minute med check. It pays my PhD psychologist $90 for an hour (50 minutes). The disparity in pay is obnoxious and uncalled for. The psychologist does more to help me than the psychiatrist ever will... until he decides to get off the assembly line, but I doubt that will ever happen. What IS about to happen is my psychologist is about to drop my insurance company because they cut her from $110 to $90 out of the blue and for no reason. While I don't blame her, I am pissed off at the system of commercial insurance that penalizes those who help and rewards those who churn out med checks like there's no tomorrow. This is a bad system. And 15-minute med checks are not appropriate care. They should not be paid for those... or they should be paid a cut rate since they're doing a cut-rate job.

S said...

Thank you, Dinah, for highlighting what was nagging at me about that article! (I came straight here after reading it.)

moviedoc, i personally would have preferred to read about the decisions faced by a more complex, three-dimensional shrink. This guy came across as a caricature, and i think it'll be way too easy for readers to jump to the "they're only in it for the money" argument/dismissal (one of my pet peeves).

The bit about the patient who couldn't get in for X amount of time made me sad, and i think that issue could have been explored further. I've known and spoken with a number of people who waited for months to get treatment at the sliding scale clinic, even knew a few fellow inpatients who checked themselves into the hospital just because that was the only way they could see a psychiatrist in a timely fashion.

Anonymous said...

@moviedoc - I would be happy to see my primary care doc only. Unfortunately he prefers I see a specialist and will not prescribe the meds

moviedoc said...

@anonymous. I like primary care docs like that! More business for me!

Anonymous said...

"350 for 45 minutes is about a dollar thirty per SECOND."

I guess if people are willing to pay that then I don't have a problem with it. I wouldn't do it, because I can't think of any advice that would be worth $1.30/second.

My therapist doesn't take insurance, but back when I saw her as a broke college student I paid sliding scale of $50/hr (normal rate was $120/hr) plus an ice cold diet coke thrown in. She's very gifted and stays busy. Best therapist I ever had.

Leslie

moviedoc said...

Anon: it's a lot but not that much. Move that decimal point back where it belongs: 13 cents per second.

Anonymous said...

Clarification: I was the recipient of the diet coke not vice versa. DIdn't word that very well.

Anonymous said...

Moviedoc, should have checked the previous poster's math before quoting it. You're correct. But, again I have no problem with it if people are willing to pay it. I wouldn't pay it even at 13 cents/sec, though. The words of wisdom would have to be very profound and earth shattering at that price.

Leslie

Anonymous said...
This comment has been removed by a blog administrator.
Shannan said...

I am a 3rd year pre-medical student right now with the intent of becoming a psychiatrist. I want to engage in psychotherapy as well as prescribe medication because I feel like the best person to treat you with drugs and talk therapy is the person who know you the best. This article really worried me. I knew before that there was a move in this direction, but I had no idea how widespread it was.

I was wondering if you have any advice. I don't want to be a doctor if I am not a Psychiatrist, but I much prefer Psychiatry (with therapy) to psychology because I believe that mental health and physical health have a complex interaction that can be best understood from this paradigm.

Dinah said...

Shannan,
Become a psychiatrist! Most psychiatrists don't see 40 patients a day. Some do. There is a backlash to the 15-minute-meds movement and a demand for psychiatrists that provide therapy-- but you won't be retiring on a yacht. The NYTimes article was a sensationalized piece of journalism, it doesn't reflect all of psychiatric care.

tracy said...

Shannan
i think it would be fabulous if you become a Psychiatrist who does therapy. There are SO f e w left.

Start a trend!

Best with Medical School...wish i could be young again and there with you!

moviedoc said...

(The cynical view.) If you want to prescribe and do psychotherapy, learn marital and family therapy at a good program, then become an advanced practice nurse practitioner. You'll still have some good years left when you wake up to the error of going into medicine. If you do go to med school there's a good chance you'll realize almost any other specialty, probably surgical, will be more satisfying and more valued by your society.

Dinah said...

Actually, I think I do quiet well at both psychotherapy and pharmacotherapy, thank you. It may sound good to say someone can't do both well, but show me the data.

On 40 patients a day, I would like to venture a guess that neither gets done well. Maybe I'm slow on the uptake here, but I have patients on 4 and 5 different meds and it often takes me a little bit to assess if a medication needs to be changed at all, why, and which one.

If the doctor had been portrayed as believing that this was a better model, as moviedoc does, I would be less upset with the article. There are probably good reasons for the med management model: I see a few patients, he is offering treatment to 1200 people, most of whom would not be able to afford care from the likes of me, many doctors don't like doing psychotherapy, many patients don't want psychotherapy, and accepting insurance is the socially responsible thing to do. That really would be fine. But this guy likes doing psychotherapy, feels it is better care, and everything about the presentation of him says he is compromising all his values. He may be totally different, it's a journalist's selected portrayal and I imagine a lot is missing or distored---Harris probably resents his psychiatrist and wanted the opportunity to paint psychiatrists as money-grubbing.
If you want to hate docs and believe they don't care about you, only care about money, then this was the article for you. If the point was that poor insurance reimbursement is pushing psychiatry to a bad place, well that got lost in the noise.

I'm still mulling over 1200 patients. I was the medical director of a clinic years ago (I met Roy there :~) ) and I believe we treated about 1000 patients and had 3.5 full-time equivalent psychiatrists for med checks, no therapy. The clinic I work in now has ? 1000 patients, and ?4 fTE shrinks. Though on clinic salaries, ain't no one moving fast enough to see 4 patients every hour.

Time for me to think about something else.

moviedoc said...

Dinah, I am confidant that your self-appraisal of your psychiatric skills is more accurate than that of most of us. Data showing on Jack of all trades, master of none (sporkiatry)? Probably about as much as that fluoxetine is more effective if the prescriber is getting a kick out doing psychotherapy with the patient, or "getting to know" the patient, which are not necessarily equivalent.

Anonymous said...

Psychotherapy is really bad paid from government insurance so far doctor can´t do it routing...

jesse said...

There is definitely something wrong with the med management model when you consider how many patients are dissatisfied with it, as evidenced from the comments here as well as others you hear. Patients are frequently angry because they feel that they are not being treated well and that the psychiatrist has no interest in them. As a consequence they do not give the doctor information necessary to make good clinical decisions.

I hope Dinah is right that there is a backlash developing, but I do not see how this can change dramatically. The problem stems from the reimbursement model. If psychologists get prescribing privileges within a very short time they will be doing precisely the same thing.

DG95 said...

I think there is a change in the way we look at the mental illness. we are not "crazy" or "depressed" anymore. we have a biochemical inbalance in our brain, and biochemical problems are treated with chemicals and not with words....Would you try to talk someone out of diabetes?