Sunday, March 6, 2011

Pumping out Prescriptions

A story on the front page of today's New York Times caught my eye - "Talk Doesn't Pay, So Psychiatry Turns Instead to Drug Therapy." For psychiatrists of my generation who've had the privilege of treating our patients in a comprehensive manner - psychotherapy when it was called for and medications when they were needed - it's a sad story.

The article describes Dr. Donald Levin, 68, who early in his career did primarily "talk therapy," with 50-60 patients in his practice who he saw for 45 minute appointments, typically weekly or twice weekly. Now he has a panel of 1,200, who he sees intermittently for 15 minutes to prescribe and manage medications. For psychotherapy they see social workers or psychologists.

Dr. Levin has done a real service with his candor. He comes across as a competent, caring person, who is trying to make a middle class living and can only do it by changing himself from a "therapist" to a "prescriber." The reporter was able to interview some of Dr. Levin's patients, who spoke warmly of him. Dr. Levin was surprised at their reactions. "The sad thing is that I’m very important to them, but I barely know them. I feel shame about that, but that’s probably because I was trained in a different era."

My professional colleagues blame the transformation of the profession on managed care. The accusation is half right.

It doesn't take a PhD in economics to recognize that fees paid to psychologists and social workers are lower than fees paid to MDs. In many areas of the country, well educated, skillful non-physician clinicians are readily available. For patients whose primary need is psychotherapy, using the insurance pool to pay a higher fee would only be justified if psychotherapy done by MDs produced better outcomes. For relatively healthy patients for whom medication isn't needed, there's no reason to see medical training as a necessary component of effectiveness. For these patients, insurers are right to pay for psychotherapy at the lower, non-MD level. Psychiatrists can do this form of psychotherapy, but won't be paid a premium for doing it.

But many patients require medication and monitoring of their physical health, combined with psychotherapy. Here, insurers have often carried over the model of split treatment in a rigid and short-sighted manner. Many years ago my psychiatrist friend Bill Goldman, then medical director of United Behavioral Health, demonstrated that integrated treatment of depressed patients with medication and psychotherapy, done by a single psychiatrist, was actually less costly than split treatment for comparable patients, with the psychiatrist handling medication and a non-MD providing psychotherapy.

In past decades, my guild made a typical guild error. We claimed that psychotherapy done by psychiatrists was better than psychotherapy done by non-MDs. For patients who needed integrated treatment, my guild's claim is true. For patients whose need was for psychotherapy alone, our claim was false.

Our defensive posture weakened our bargaining position with insurers, and the insurers' short-sightedness about the validity of integrated treatment with a subset of patients made them hard to bargain with. The result has been a large scale transformation of the profession into one where psychiatrists do intermittent "med checks," described in poignant detail by Dr. Levin in the New York Times.

In 1975 I joined the practice in a not for profit HMO, in which the insurance function and the medical group were part of a single organization. I and my psychiatrist colleagues shaped our practices so that we cared for patients for whom our medical training provided additional value. Patients who needed psychotherapy alone went to our excellent non-physician colleagues. This arrangement was (1) satisfying for patients, (2) satisfying for clinicians, and (3)an efficient use of the insurance pool. It required trust between the clinical and insurance components of the organization.

If the anticipated trend to encourage the development of accountable care organizations - medical groups that take responsibility for quality and cost - unfolds as predicted, we'll see recalibration of psychiatric practice. Psychiatrists will be paid to talk and prescribe, but only for the subset of patients who require their combined expertise. That could foster good clinical care, good professional life, and good economics!

(For more about the transformation of psychiatry, see my post "Psychiatrists should talk with patients, not just give pills.")


Anonymous said...

It seems to me that for the very serious mental illnesses such as schizophrenia, present insurance practices that refuse to cover proper and thorough treatment regimens via integrated care by experienced MDs, can lead to treatment-resistent forms of these conditions. Are there any studies linking short sited Insurance practices with poor outcomes and increased long term treatment costs?

Jim Sabin said...

Dear Anonymous -

Your comment is exactly on target. It's been well demonstrated that failing to invest in solid treatment for people with an ailment like schizophrenia leads to what has been called the "revolving door," with frequent short hospital admissions and poorer long term outcomes.

From an economic perspective, the problem with our health system is that long term outcomes (including costs) often don't accrue to the insurer who invests in the right kind of treatment. This is because of the turnover in insurance coverage. (In Canada, where insurance is provided by the state, this problem doesn't occur.) And in the U.S. system, which is built around competition, getting a reputation for doing an excellent job with folks who have serious long term ailments can be a mixed blessing. From the perspective of professional ethics, that's what health care is all about. But from the perspective of institutional finance, it can lead to a disproportionate number of people with the ailment who select that insurance. This is of course a wise decision on their part, but over time "adverse selection" can harm the overall viability of the insurance program.