Psychiatry’s Lesson for Universal Health Care
As President Obama tries to remake the American health care system, the gutting of psychiatry by insurance company policies and other administrative forces is a good lesson in what to avoid.
The endless red tape inherent in dealing with many insurers and the loss of professional autonomy to insurance company “reviewers,” has led many of the best and brightest psychiatrists and psychologists to accept no insurance reimbursement at all. Psychiatrists have, if you will, acted out Atlas Shrugged, Ayn Rand’s cautionary tale of what can happen when institutions throttle individuals. They’ve walked away and taken their gifts as healers with them. In fact, when I refer patients to other mental health care professionals, it’s very challenging for me to find clinicians I consider in the top echelons of my field who will accept third party reimbursement of any kind. A brain drain has siphoned off access to some of the wisest counsel available in psychiatry, except for those willing to pay cash, and I believe the same could happen (or greatly accelerate where it already is happening) in other medical specialties.
The influence of insurance company policies has also led to the public being served by professionals from allied health fields, such as clinical nurse specialists. The need or desire for these companies to save money, which will only be accelerated by the current Obama plan, means social workers and nurses are the preferred providers of psychotherapy and medication evaluations to those battling depression and schizophrenia and bipolar disorder. This phenomenon could find its reflection in the firm ground of internal medicine and endocrinology and obstetrics and other specialties yielding to intellectual quicksand, in which the knowledge and skills of physicians often disappear from the landscape entirely.
There’s nothing inherently wrong with getting your health care from physician assistants and nurses. But these folks didn’t go to medical school, and didn’t complete residencies, and if I were confronting a serious condition I’d want to be treated by people who had. I’d pay for it out of my own pocket. And my guess is that we’ll end up having to.
Oh, one more thing: Not only did many psychiatrists walk out on the system, lots of the ones who stayed let their practices be shaped by insurance company reimbursement policies that pay them more to prescribe medications than to talk to people. So there are a whole bevy of shrinks who’ll see you for ten minutes once a month and just write you a prescription. It actually pays pretty well, even if it leaves them out of seventy percent of what can restore patients—effective, expert psychotherapy. That medical art is in danger of extinction.
See, Obama’s eight principles for overhauling health care address economics, access, prevention, safety and cost. They don’t address how to preserve the core of the world’s most successful, powerful, inventive health care system ever: the contributions and creativity and commitment of America’s physicians.
Tags: Dr. Keith Ablow, health care, patients, physicians, President Obama, prevention, psychiatry, psychotherapy, universal health care
Share
Although I completely agree with your assessment of the problems with the health care ststem, I feel you somewhat devalue the role of “allied health professionals”.
As a licensed clinical social worker I am licensed to provide psychotherapy services in New York State. I hold two master’s degrees, and have over a thousand hours of additional training.
Here in Suffolk County I do not know of one psychiatrist who provides psychotherapy. Inlcuding those who only accept self pay patients. I also believe that the ability to be an effective psychotherapist goes far beyond education, and some of the most well educated people I know lack any ability to adequately communicate genuineness, empathy and respect.
I have worked in both inpatient and outpatient mental health programs, as well as own my own private practive. As a social worker not only am I skilled in the practice of several modalities of psychotherapy, but I am an expert on concrete community resources.
Greed and lazziness has gotten this country where it is with Health Care.
in 30 yrs. of nsg., most of it psychiatric, there were only a few in the late 70’s and early 80’s that afforded psychotherapy from a physician. then came the dreaded DRGS from insurance that mandated very little in prevention and luxuries like long-term talk therapy. cognitive and behavioral treatments were the didactic tools of the trade. along with the meds.
meds are so much better. almost too good and now the coping skills, interelational skills have been largely ignored as so much of psychiatric disorders have been shunted to the primary care physician. That is the big issue as I see it. Bipolars are misdiagnosed because the docs don’t know how to assess in their 5 min. cursory look down the pike. Nurses have those skills and psychiatric nurse practitioners with a psychiatrist in the practice is a great way to go. Nurses, for one, are trained to be wholistic, and that is a bottomline plus. Docs are disease oriented. Problem solvers.
One must finesse the system. I urge my friends and family with persistent and irritable mental illness to stop putzing with their family doc and his meds that provide so-so relief and no assess of the big picture–since I present as functioning tres normal and have bipolar/anxiety disorder for years I sing the praises of my shrink however little time I have with her because it is quality that counts
Universal health coverage : What really needs to happen is cost control not so much on the physian they are worth their wieght in gold but on the pharmacy portion of health cost. Example in the UK insulin for diabetic cost is one half of what it costs here. In the UK my triple by-pass surgery with flight over there private room everything included meals ect.. 20,000 us dollars. Here 240,000 dollars. Same surgery using the same types of medications and everything. Why so cheap? Cost Control on the pharmaceutical. When something cost only 50 cents to make and you sell it for 5.00 dollars that is not progress that is robbery.
Every psychologist and medical doctor I’ve ever met has voiced the opinion that insurance companies are the bane of their existence. I know one physician who actually changed professions due to the frustration of having to comply with insurance companies’ demands.
This isn’t a new phenomenon, though I doubt the “Universal Health Care” overhaul is helping matters any…
While there are many gifted people continuing to practice under the ever-watchful (and extremely time-consuming) eye of insurance companies, they may find themselves either having to compromise their true beliefs regarding what would actually help their patients, or having to flat out lie to “The Man”, so they can continue to do their jobs with impunity. Very unfortunate. I do not envy them.
Every psychiatrist I’ve ever met via insurance, has done exactly what Dr. Ablow said: talk for ten minutes, and whip out that trusty prescription pad.
I think Dr. Ablow stands alone as a psychiatrist in that he actually does want to “go there”, find the roots of peoples’ problems, and work hard at helping them overcome their psychological obstacles. I apologize if there are other psychiatrists out there who do the same! If so, kudos to you!!!
There’s a tragic Catch-22 here. The people who most need psychological/psychiatric help are generally the poorest (and not necessarily the laziest) among us–homeless schizophrenics come to mind. How on Earth are we as Americans going to help these folks? I wish I had an answer.
Doctor, you are so very right. Three to five days in a psychiatric hospital is about all you will get for the grossly psychotic patient, then you have to battle with a reviewer to squeeze out another day or two. Most of the time free services are necessary to remain ethical and keep the patient safe until stable.
Physicians are key to teaching and working with non physicians in giving care to the greatest number of people. Every community I have worked in has had problems with access to psychiatrists for patients with mental health issues. If more non physicians were adequately trained to treat garden variety depression and anxiety then the more severe cases could be physician managed. There are many who go untreated for the want of care from any provider.
Some MD’s, not psychiatrists, are reticent to treat mental health issues due to a variety of concerns.
Health care is a team approach. Physicians are the leaders yet non physicians make an important contribution to health care delivery which increases access and decreases costs.
Terry Manlove CNM MS
Certified Nurse-Midwife
Let us hope that
we can overcome…” the intellectual quicksand
by way of better insurance plans
and more concern for health by this government.
Maybe when they see the number of people
that are costing society by being
dysfunctional and without help….that
real medical care..psychiatric care will return.
The comments about what will happen to psychiatry with Obama’s health care plan is already happening in public mental health which has become an over regulated system that largely uses the psychiatrist as a medication dispensor with little if any time to truly treat the patient. Non medical administrators come up with endless rules and regulations that actually inhibit the physician’s ability to address the patient’s problems, which generally have an extensive psycho-social aspect. The 70% mentioned is often an under estimation of the psycho-social contribution to the presentation and complaints.
The “new” mantra is outcome measurement. It is expected that patients will improve or get well with the treatment provided by the physician. Yet most of the tools required are not available to us in the public system. Examples are lack of time for psychotherapy, holding patients responsible for following treatment plans, having the patient be invested in his/her treatment, formulary restrictions, etc.
Before rushing into a government controlled health care system one should reflect on governments performance in other areas, such as social security as an estimation of how effective they will be with in this endeavor.
Access to care is going to be the biggest challenge with universal healthcare, we might be able to solve problem of financial access but what about the supply issues? Boston today have the longest wait times for doctor appointments in top 15 cities, Philadelphia is number 2.
We are trying to solve the issue of access in a new way DocAsap.com is an online platform that lets patients book doctor appointments at a click of a button online. By realtime information flow DocAsap.com would be matching patients in need of care with real-time physician and dentist availability. Doing this DocAsap will
1) increase practice utilization,
2) decrease over use of emergency rooms
3) unearth hidden capacity due to cancellations and no-shows, and
4) increase access to care for patients.
DocAsap recently launched in Philadelphia and would have all specialties soon, Psychiatry being the second one.