Matthew Mintz: As psychiatry goes, so will primary care

The following is a reader take by Matthew Mintz.

Despite being mentioned on ABC News, and the medical blogosphere, the recent study in the Archives of General Psychiatry that shows psychiatrists are less likely to use “couch” therapy hasn’t garnered the attention it deserves.

The study found that for patients who saw psychiatrists, the percentage of visits involving psychotherapy (where the physicians talk to you) decreased from 44.4 percent in 1996-1997 to 28.9 percent in 2004-2005. This is despite that fact that psychotherapy has been found to be effective for many mental health disorders. The authors and commentators note that the way in which psychotherapy is reimbursed (“reimbursement for one 45- to 50-minute outpatient psychotherapy session is 40.9% less than reimbursement for three 15-minute medication management visits”), but the findings go far beyond that and are a good indication of the future of primary care.

What is not clearly stated in the study is that in 1996-97, about 55 percent of patients who paid out of pocket received psychotherapy compared to about 40 percent who paid with insurance. In 2004-05, the percentage slightly increased for patients paying out of pocket (59 percent), but dropped by almost half (23 percent) for patients using insurance. The reality is that over the past decade, the way in which psychiatry is practiced and delivered has dramatically changed based on reimbursement structures. We now have two types of care delivery for mental health services.

In general, there are two types of psychiatrists whose practices are remarkably different: those that accept insurance and those that do not. For those that do not take insurance, psychiatrists prescribe medication, administer psychotherapy, or do both. Those psychiatrists not taking insurance generally manage medication only, using other health care professionals (psychologists, licensed psychiatric social workers, etc.) to administer counseling and other forms of “talk therapy.”

For many insurances, mental health is a carved out benefit. In other words, instead of getting a referral from your primary care physician to a specialist who accepts your insurance, patients needing mental health care must call the central number of the company their insurance contracts with, and speak to an intake person, who is usually a nurse or social worker. This person will then authorize therapy and direct the patient to a covered provider. Sometimes they determine whether or not a psychiatrist is really needed or whether a non-physician provider can do the job. Alternatively, some mental health benefits direct all patients to a psychiatrist initially, whose main job is to manage medication and direct patients in need of counseling to non-physician providers.

This description is by no means intended to discredit psychologists or psychiatric social workers, who provide excellent and effective care. In fact, I am not even arguing that this is a bad system. With limited health care dollars, maybe it makes sense for MDs to focus on medication, and non-MD professionals to deliver cognitive services. The point is that the low reimbursement for cognitive services from both government and private payers has dramatically changed the way mental health care is delivered in the US, transforming it into a two tiered system. More importantly, the same is likely to happen to primary care, where much of the work of the primary care physician is non-procedural.

The rise of concierge care is only the beginning. Unless there are substantive changes to the way cognitive services are reimbursed, specifically for primary care, general health care will similarly develop into a two-tiered system for those patients who pay for primary care with health insurance and those that pay out of pocket. Having a primary care physician that knows you as an individual, calls you back on the phone to answer questions, fits you in to an appointment when you are sick and takes the time to talk to you in an unrushed visit will only be available to those that can pay for these visits out of pocket.

Those paying for primary care with insurance should expect (in the not too distant future) limited access, routine care delivered by PA’s and NP’s, and rushed visits with the MD, whose primary focus will be medication management and directing you to non-physician providers for counseling and discussing your various health concerns. Health care reform that does not address the central issue of low reimbursement for cognitive service and high reimbursement for procedures and diagnostic studies will only encourage this shift.

In fact, this trend has already started.

Matthew Mintz is an internal medicine physician and blogs at Dr. Mintz’ Blog.

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  • Michael Rack, MD

    “Those psychiatrists not taking insurance generally manage medication only”
    many psychiatrists these days are only managing meds. However, it is the non-insurance taking psychiatrists who sometimes also do psychotherapy. The pscyhiatrists who take insurance are more likely to do the 15 minute med check visits.

  • Anonymous

    I have worked in no-insurance private practice model, where I provided comprehensive outpatient psychiatric care, in a managed care model where I did almost only med checks and relegated psychotherapy to social workers (they thought psychologists too expensive). Now I am the administrator managing other psychiatrists utilization.

    One thing that I am careful to never do, and that is to defend the current insurance model as delivering superior or even equal quality of care to the model that prevailed before most people had psychiatric coverage. It is clear to me that the FFS model where the care is integrated in the hands of a single clinician (as long as that doctor was adequately trained-some aren’t), and where the relationship is solely between doctor and patient, and each has a direct personal and financial skin in the game produces clearly superior care and outcomes.

    Some studies also strongly suggest that in the end, it is actually cheaper as well. I find that entirely plausible.

    I can easily imagine that it is the same for primary care. In fact I am so convinced of it that I have searched for an internist or family physician in my area who practices on that basis but can find none.

  • Mother Jones RN

    Not every problem can be cured with pills. I think that cognitive therapy is being black balled because many decision makers working at HMOs are prejudice against mental health patients. Even after many years of trying to educate people about mental health issues, there is still a prevailing “just pull yourself up by your bootstraps” attitude among many people working in healthcare. I’m a big believer in cognitive therapy. It works.


  • Frank Drackman

    Have you EVER talked to a Psychiatrist? That they’re only managing Meds is a good thing, You’ll get better Psychotherapy from a East Asian Cab Driver. Just my 2 cents.

  • Steven Knope, M.D.

    I am a concierge physician (internist) with 8 years of experience in this area. A psychiatric colleague is joining me in my office next month to start a private practice, independent of third-party payers.

    Matthew Mintz is correct; psychiatry is going the way of primary care medicine. The only way for cognitive medicine to survive is for doctors to be paid fairly for their services. If the system is broken, the only rational response for a doctor is to “opt out.” For doctors to remain in a system that abuses them and abuses their patients is nothing short of “medical co-dependence.”

    Steven D. Knope, M.D.
    Author, “Concierge Medicine; A New System to Get the Best Healthcare” (Greenwood/Praeger, May 2008)

  • Anonymous

    I had a troublesome child who saw an insurance therapist with poor results mostly because he wasn’t interested. She said to me – if you want a predictable appointment pay for it privately. The insurance environment also put you in a group session after just one/two individual ones.

    Several years later I needed some mental health help, and remembered how chaotic and difficult the insurance environment was — so I found a therapist down the street from work, and paid privately.

    It was well worth it, I had an appointment that worked with my schedule, my flexible spending account reimbursed it AND I got better!

    I worked hard at it, read every book she ever mentioned and thought carefully about her suggestions. To this day I use some of the things she showed me.

    I think having a predictable appointment and not getting shuffled into a group session was a big help.

    Too many people shy away from funding their FSA accounts because they might lose the money. If you put money in there more likely than not you will manage to spent it — possibly with superior results.

  • Anonymous

    I had a patient for whom I managed meds while she saw non-medical therapists provided psychotherapy. 2 social workers and 2 PhD psychologists later she was more traumatized than before. While rusty with my psychodynamic psychotherapy skills, it seemed apparent that it was what she needed–not more roughly administered cognitive therapy–and I was the only person she might get it from. Amazingly, her insurance agreed to cover it–at my fee, not theirs– and she did very well once she got what she needed. But the insurance would only cover what she needed after a lot of time, money and suffering was put into “money saving” shortcuts.

    BTW, I wouldn’t blame all the decline in psychotherapy on insurance stinginess or doctor greed. All other things being equal, the general public just doesn’t want it like they use to. People are enamored with the idea that the right dose of meds will make everything hunky dory with no hard work needed.

  • Anonymous

    Regarding Frank’s observation: I can not rule out the possibility that it is well founded based on his experience. A lot of people in psychiatry are an embarrassment–thanks to the fact that it doesn’t fill it’s slots and irresponsible program directors will take warm bodies where ever they can get them for the cheap labor to serve their public clinic and public hospital patients. The result is that people who shouldn’t be in the specialty in the first place not only end up in it but with the worse possible training.

    In part this is all a result in the first place of what third party reimbursement has done to cognitive services in medicine–therefore the poor match into psych residencies.

    There is the other half, the better half out there. But Frank probably never sees them because good psychiatrists soon learn to hide from other doctors. The reason is that the doctor, upon finding he has found a “normal” that he feels comfortable sending patients to, will send all of his severely chronically ill patients to the guy. Unfortunately, they are all on Medicare and Medicaid and so the shrink will starve to death if he gives them time to deliver good care, he will compromise his dedication to quality that made him a desirable consultant in the first place if he provides the care that he can afford to provide. The referring doc complains if he doesn’t take the insurance and charges fee for service (because the patient then complains).

    So he soon learns to just stay away from other docs lest they like him and this cycle starts over. The only guys who Frank can therefore find to talk to are the other half.

    Just a hypothesis.

  • Dr. Matthew Mintz

    Thanks for all your comments.
    Dr. Rack, the sentence you quoted was a typo. It is the psychiatrist that take insurance who (generally) only manage medication. Sorry if that was confusing.
    Also, I do recognize that some of the decline in psychotherapy may be due to medications such as anti-depressants being more widely available, cheaper, and more acceptable to patients. We are indeed a quick fix, pill popping society. However, the patients who paid out of pocket actually had an increase in psychotherapy. If increased availablilty and acceptance of pills was a strong factor, one would expect a decline in both groups. Though it is possible that patients wanted pills so they felt they might as well go to the doctors taking insurance who would prescribe them, I doubt this is a likely scenario.

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