Friday, July 13, 2012

The Racket We're Making on Clinical Psychiatry News

Are "med checks" as the mainstay of psychiatric care just a racket?  I wrote about this on our column over on Clinical Psychiatry News.  While I think that brief med checks are fine for some patients, and even all they might want, as a standard paradigm for psychiatric treatment in a one-appointment-length-for-everyone, I think this is destroying psychiatry. What do you think?

And speaking of rackets, Roy had a article up there last week on Insurance Networks and mental health parity.  Does your insurance network list psychiatrists who aren't taking new patients, who don't see outpatients, who only do research, or who are dead? 

And just in case you missed it, Clink had yet another article about maximum security prisons, federal lawsuits, and the treatment of prisoners. 


jesse said...
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Sunny CA said...

Med-check appointments may suit some people, but I know a woman who had a med-check psychiatrist before she lost her home in Katrina, then moved to Georgia where her general practitioner prescribes for her. During all those years, her life could have been immensely helped through some form of psychological therapy. In Georgia, her friends urged her to get counseling, but she felt that nobody could counsel her who had not lived through the flooding themselves. She's been "robbed" of her mental health as a result of the med-check system and the general practitioner taking over the psychiatrist's job (which is easy because all they do is write prescriptions).

My psychiatrist still does 50 minute sessions. He's been practicing more than 40 years, though, so is one of the old guard. The change in psychiatry is sad.

George Dawson, MD, DFAPA said...

It IS a racket and I have blogged and commented about it many times. But let's define whose racket it is. Contrary to the popular notion that this is a way for psychiatrists to enrich themselves the med check is the product of government regulations and the managed care industry. There will always be people gaming the system and charging a high fee for a prescription but the average employed psychiatrist puts in a grueling day and the reason for it is that clinics are set up on the basis of 20 minute med checks largely because of poor reimbursement by managed care companies and the state and federal government payers.

I don't know if people are aware of the special billing arrangements for psychiatry that differ from other physicians. At times and in many circumstances psychiatrists are prohibited from billing E & M codes like other physicians. E & M code billing allows more time for assessment and treatment because it reimburses at a professional level rather than the 90862 med check level.

It follows that the care that followed went to the lowest common denominator.

Anonymous said...

Pick any non-mental illness, any illness. If, to fully treat your chosen illness, both a drug and therapy were required, would you consider it ethical to only treat with drugs? Say that, without it, we can manage it just fine for as long as we like, but the drug's side effects run the risk of killing your patient's kidneys down the line; however, combined with therapy the patient may only need to be on that drug for two years instead of forever and the longer they're on that drug the longer they're at risk. Would we consider it ethical to only treat with drugs? I mean, really, they might not end up with kidney damage, right?

Pick another non-mental illness. To treat your chosen illness, you have at your disposal a drug that's known to be addictive. There are other drugs, they kind of work, but this one's really powerful and it kicks in really fast. Maybe you decide to prescribe both. You also know that with therapy, the client may only need to use the addictive drug in emergencies instead of daily, and with enough therapy they may not need either of those drugs for very long. Would you consider it ethical to prescribe your patient that addictive drug without also providing therapy?

If kidneys required therapy, the liver, the heart, the lung, if they all required therapy in order to bring our patient to full remission... would we consider it ethical to only treat with drugs?

Is it a racket? No. Psychiatrists were lead to where they are now, they didn't do it on their own. However, to acknowledge that the issue exists and then allow it to continue is highly unethical. Just because Dr. Bob down the street is willing to treat his clients halfway, just because Corporation A says they want it this way, doesn't make it okay for you or any other doctor to do the same. When you spend more time listening to Corporation A than your client, you can't expect the client to trust you with their health.

So really, it's, “Don't expect us to trust you when you're only willing to do half your job”.

And for clarity's sake, I do mean You in the global sense, not directing toward any individual.

jesse said...

Wow, Dinah, your post is right on. Other medical specialties have been affected by insurance reimbursement, but psychiatry has been transformed by it. Psychiatric residents don't get jobs doing psychotherapy and residencies have modified their training accordingly. There is no going back. Irv Cohen once proclaimed at the APA that "philosophy follows funding." It is one of the fundamental laws of the universe.

There are still many psychiatrists who see their patients for more than just a "med-check." The problem with the med-check is that, as many patients have told me. they quickly discern that the the psychiatrists are interested in nothing but the symptoms, and so tell them nothing else. 

They are interested, they feel, in the symptoms rather than in them.

The best of these doctors are truly good at what they do. They know psychopharmacology at the most expert level. This is to the good. But the field of psychiatry is no longer about understanding psychopathology in the wider sense.

This topic really is an extension of the discussions about good and bad therapy. If psychiatrists do not talk with patients how would they learn the extent that talking can be helpful?

Anonymous said...

I like my med checks.

My insurance - I have blue shield of california, I searched on the site for psychiatrists, and there is not a single one in network. No psychologists either. That doesn't seem like parity, but maybe it's the choice of the providers.

Anonymous said...

@anonymous with blue shield of california. I have BlueShieldCA too -- they list mental health providers (psychiatrists and PhD/LCSW/MFT therapists) separately from the rest. The website is confusing & I can't speak to your specific plan of course but keep looking: I certainly have a lot of psydocs in network to choose from.

Kamalks said...