Comments on: Matthew Mintz: As psychiatry goes, so will primary care

By: Dr. Matthew Mintz

Dr. Matthew Mintz — Tue, 19 Aug 2008 22:45:00 +0000

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.

By: Anonymous

Anonymous — Tue, 19 Aug 2008 00:45:00 +0000

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.

By: Anonymous

Anonymous — Tue, 19 Aug 2008 00:34:00 +0000

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.

By: Anonymous

Anonymous — Mon, 18 Aug 2008 19:37:00 +0000

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.

By: Steven Knope, M.D.

Steven Knope, M.D. — Mon, 18 Aug 2008 14:42:00 +0000

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)

By: Frank Drackman

Frank Drackman — Mon, 18 Aug 2008 14:04:00 +0000

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.

By: Mother Jones RN

Mother Jones RN — Mon, 18 Aug 2008 13:53:00 +0000

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.

By: Anonymous

Anonymous — Mon, 18 Aug 2008 01:41:00 +0000

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.

By: Michael Rack, MD

Michael Rack, MD — Mon, 18 Aug 2008 01:01:00 +0000

“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.