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Loading ...I feel backed into a corner.
We got a phone call from the parent of a child who has been seeing a psychiatrist that closed his practice. The soonest appointment the family could get with a new child psychiatrist is in July, and they are now running out of medications. So who do they call? Who else? Me. They don’t want changes in dosage; they just want me to maintain things where they are. It sounds reasonable.
It really scares me. I am not a psychiatrist, let alone a child psychiatrist. I was not trained to use psychotropic drugs any stronger than typical antidepressants, yet now I am being requested to do so. If it was an adult, I could rationalize it by noting that I give a lot of “risky”drugs to adults. But this is a young child.
So why don’t I just say “no”? The pleas from the parents are hard to ignore. I have cared for this child from birth, and have deep trust from the parents. I was the one who suggested psychiatry in the first place. My rejection wouldn’t force the parents to look elsewhere; it would mean the child would stay unmedicated for several months.
“She can’t go to school without them. She is unmanageable – she just can’t control herself.”
So this is my choice: protect myself and harm the child, or treat the child and go against all my better medical judgment. I either prescribe drugs I don’t know in a kid, or force her to go out of control. There is no good way out.
Why does this happen? Here’s the answer from the Wall Street Journal health Blog:
Two-thirds of primary-care physicians in a nationwide survey said they had trouble finding high-quality mental-health treatment for their patients while only a third had difficulty getting patients a referral to specialists for other types of medical services, according to a study published in Health Affairs today.
Absent or inadequate insurance coverage and a lack of mental-health providers were the top reasons that the doctors reported for the difficulty in getting high-quality mental-health referrals for patients.
Why do you think this is? There isn’t a shortage of cardiologists. I have no trouble finding dermatologists. I don’t get stuck prescribing chemotherapy to people who can’t find an oncologist.
The problem is obviously reimbursement. Primary care is not at the bottom of the reimbursement ladder, psychiatry is. You don’t often see one group of doctors championing increased reimbursement for another specialty, but that’s what I am doing. We need psychiatrists, and to get them we need to pay them better. When we don’t, it’s not only the psychiatrists that suffer. It’s not just primary care physicians.
It’s the desperate parents and the kids who suffer.
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{ 11 comments }
Huge problem. Many in my area do not even take insurance and mandate cash payment at this point.
As a psych patient, I have dealt with the shortage of psychiatrists multiple times. It’s extremely aggravating when you’re already not doing well to have to fight insurance companies and call around to find someone to treat you… but not for another four months when they have an opening for a new patient.
As someone in PA school and going into medicine, please help me understand – what has to happen for reimbursement levels to change? How do we convince the insurance companies that psychiatric services are worth more?
Thanks for the nod, Rob. I’ll answer Medicated’s question.
The primary thing to do is to make it easy to get paid. Imagine owning a restaurant where, in order to get paid via credit card, you had to submit a form requesting permission for each customer to use the card. Then, when you got permission, then you could serve them their meal. Then you submit the bill to the credit card company. But if the credit card company only permitted them to order noodle entrees, and the customer chose General Tso chicken, you’d have to submit another request for the variation, then if it gets approved, submit the bill again. (You might have to call and speak to someone to get a verbal preauthorization, maybe.) Oh, there’s a fair chance that it might get turned down for payment anyway. But if you appeal it, there’s a good chance it will get paid if you spend the time to jump through that hoop. And, after all that, if the customer liked your meal and service so much that they came in again next Friday night, you’d probably have to go through the whole thing again.
It’s no wonder that your restaurant above would say “forget about credit cards, I’m only taking cash.”
Most mental health providers are one-person shops. There is not a huge front office or even a secretary for most. Most of these providers handle their own billing and phone calls themselves. So, it is no great surprise that they will not work for plans with a lot of red tape. Which is why many will take Medicare (easy to bill, no hassle), but not Blue Cross or Medicaid or Cigna. Better pay would definitely help… rates in our state for most insurance companies have remained the same or dropped over the past 15 years — despite the cost of living increasing more than 50% over the same time period.
So, these are the two main things that need to improve.
And, how to convince insurance companies to fix this?
1-They have to stop using third-party carve-outs. With a carve-out, they pay a fixed amount to a company, like Magellan, who then makes money if they collect more than they pay out. Problem is, when these visits are not tracked by the main payor, they don’t notice that poor performance here may lead to higher inpatient costs, or ER costs, or medical costs. Can’t tell you how many times I see a PCP hospitalizing someone for “dehydration” or something minor, when the REAL reason is to get them a psych consult while they are in the hospital, because they couldn’t find someone to see them on the outside. Happens all the time. At what cost?
2-Get your employers to make a stink about only paying for health insurance with good MH benefits. Good luck with that.
3-Speak up. Make a stink. Collect data. Tell your legislators that you or a family member or an employee have an illness for which you cannot get timely help. Don’t let the stigma hold you back. Speak up so they can see that everyone with a MH illness is not “crazy”. That people with MH problems are not just “them,” they are “us.”
Here’s a good one. Call every single psychiatrist listed in your insurance company directory in a 50-mile radius and find out if each is accepting new patients. If so, what is the wait time to be seen. If not, what are the reasons. Such as Retired, Deceased, not accepting new patients for that insurance company, practice is full, don’t have an outpatient practice because just sees inpatients, etc. Now organize your info and take it to your elected representatives. Ask them to pass a law that penalizes insurance companies for providing this false information. Or one that requires these directories to indicate next to each name, how many new outpatients were seen by them in the most recently available 12 months. This would expose the phony “networks” that they have.
That’s enough for now. Thank you.
wow. I did learn some things, and definitely have some things to think about or try in the future. Thank you for the thorough and timely response!
So you know, my interest in the subject isn’t just about increasing availability. I really appreciate the work that you and your colleagues do; I probably owe my life to the keen psychiatrists who helped get me to a “better place” a few years ago. For this reason, I find it very disappointing that psychiatrists are basically the lowest-paid physicians out there. I genuinely value what you do and personally wish your financial compensation reflected more accurately on the value of the services you provide.
Nice post, Dr Rob. Surprisingly I’ve been asked by patients (adult ones) to write the same scripts for them. I don’t mind giving them a script for Xanax perioperitively, but not long term anti-anxiety/anti-depressants.
Very good description of insurance payment, Roy!
Thanks for this post. I knew it wasn’t just me going through something like this.
Great description Roy. In my state, Maryland, (which I believe is yours as well), the Insurance Commissioner’s Office will follow-up on consumer complaints about denials, phantom panels, etc. There are regulations in place for managed care companies to have large enough panels to prevent long waits for appointments. There was a successful lawsuit in Virginia on this issue against Blue Cross/Blue Shield brought by the American Psychological Association and others. The Attorney General in New York (Andrew Cuomo) has been particularly active in going after health insurance companies. Every state has an insurance commissioner or other entity in state government who can help individuals, so those who prefer not to go public with having a mental illness have recourse for someone to help them.
The problem is particularly severe for child psychiatrists. A recent article from Medscape stated that there are 7418 child and adolescent psychiatrists in the entire country to serve almost 74 million children!!!
Thanks to Dr. Rob for bringing up this topic.
This happens ALL THE TIME.
And when given the option between CYA-but-harm-the-patient or help-the-patient-but-assume-medicolegal-liability, we tend to all choose the higher ground. Not without a bit of heartburn, though.
The same issue arises in adult patients, especially bipolar patients who need the care of a psychiatric team to stay healthy, but who have lost insurance. Their access problems are even more thorny.
What is worse, inadequate care or no care? I hope it’s better for me to do what I do, but some days I wonder. Are the bandaids that primary care is constantly providing doing nothing but hiding the hemorrhage?
Probably not realistic to ask the Shrink to work the patient in…or stay late one afternoon…What am I thinkin?!?!? Next thing I’ll be seein a Psychiatrist…
Another possible reason people avoid psychiatry is because those who are interested in mental health might be more drawn to the non-prescribing degrees- PhD/Psyd. Obtaining a PhD is normally free and Psyds, while expensive, take a lot less time to complete. Psychiatrists make more money than these other degrees, but a lot of the people I talk to say they chose psychology instead so they can spend more time with their patients/clients.
What are your feelings on the right-to-prescribe issue? Some states have approved PhD/PsyDs limited prescribing powers with an additional (I think 2 years) of pharm education. I understand why physicians are wary of this field encroachment, but with the lack of psychiatrists maybe its not such a bad option. It could at least free up psychiatrists from prescribing short-term antidepressants or ADHD meds so they can focus on the more complex patients, like the child you’re concerned about.
Totally against non-physicians prescribing psychotropic medications. I’m sure you are not surprised. PhDs, etc, do not have the medical training to safely prescribe, IMO. Taking a few courses and meeting with a supervisor (another non-physician) for the first 50 or 100 just doesn’t cut it.
These drugs interact with other drugs, cause side effects that affect organs other than the brain, and one needs to know about how the whole machine (body) can go wrong to tease out what may be going wrong after prescribing a drug.
I really don’t see it as a competition thing or an encroachment thing (no shortage of patients). It is a safety thing and a discrimination thing. What other specialty allows folks with no actual *medical* training to prescribe. Maybe one could argue dentists, but they get more medical training than PhDs. Also, the training that a PhD gets can vary widely from program to program, whereas US physicians get basically the same stuff no matter where they graduate from. And psychiatry residency programs give you basically the same stuff, due to RRC requirements.
Finally, one of the main aspects of psychiatry training that gets overlooked in PhD psychopharm programs is that one gets 12 (18?) months of over-the-shoulder, inpatient prescribing experience with a senior resident AND an attending physician watching your daily decisions, coaching you at every step. That is how you start. If you make a mistake, the patient is in a hospital where they are being watched daily, regular vital signs, and lab tests, etc. It’s hard to screw up badly.
The original DOD program for PhD’s mimicked this to a large degree. But *none* of the current state programs provides this at all (takes too long, too expensive, no one wants to give up their full-time private practice to take on a 3-4 year long, full-time, internship and residency training program).
I should note that I started out in college thinking about psychology. But as I learned more and more about how the brain worked, I found that I wanted to learn how the whole body worked (they are connected, you know). I found psychology to be too “soft” and fuzzy and theoretical. Too high-falutin’ for my taste
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