How a psychiatrist can write 100,000 prescriptions a year, and what that means for primary care

The Miami Herald is reporting an investigation of a psychiatrist who wrote almost 100,000 prescriptions a year. Sen. Grassley and the feds have halted payment to this Miami psychiatrist who stated that “he prescribes only what is medically necessary” and “works long hours, seeing patients for 10 minutes at a time and many of his patients need four or five medications.”

I have no personal knowledge, interaction, acquaintance with psychiatrist Dr. Mendez-Villamil. However, though this sounds fraudulent, how could this doctor personally benefit from all of these scripts? Doctors do not get paid by how many prescriptions they write. Drug companies are now forbidden to wine and dine doctors, so it is highly unlikely that some pharmaceutical rep is incentivizing this psychiatrist. Besides, these patients are Medicare and Medicaid, so they are likely getting generics in the first place.

So if there is no wrong doing or even an incentive to write all those scripts, is this even possible and why does it happen? If the good doctor is seeing patients every 10 minutes, and each patient needs 4-5 prescriptions (assuming an 8 hour day), that’s 46 patients a day needing about 3 prescriptions on average to yield the 150 prescriptions a day that Dr. Mendez Villamil is “accused” of writing.

Though this may not be good medicine, with that volume of patients, the numbers sound pretty reasonable, especially since many chronic psychiatric patients are on multiple medicines. So is it possible that one psychiatrist sees almost 50 Medicare and Medicaid patients a day in 10 minute visits? If the psychiatrist accepts Medicare and Medicaid, then this is actually quite likely the case.

In a piece I wrote for KevinMD.com a year an a half ago, entitled, As psychiatry goes, so will primary care, I described how there are two kinds of mental health care in the US: care for those who pay with insurance and care for those who pay out of pocket. The kind of care that you see in TV and movies where a patient talks to a psychiatrist and possible gets medication; that kind of care happens, but only if you are willing to pay out of pocket.

In many cases, fees for a regular sessions run over $200. For those paying with insurance, the experience is quite different. If a patient sees a psychiatrist, it is usually only for medication management and usually only in short, 10 minute visits. Any “talk therapy” is relegated to a psychologist or psychiatric social worker.

I mean no disrespect to some of the excellent and well qualified non-physician therapist we have in the US. I am not even stating that having a short visit with a psychiatrist for medication management and counseling done by non-MD’s is bad medicine. However, the public must be aware that this is how psychiatry is practiced in the US.

In the case of Dr. Mendez-Villamil, he probably is one of only a handful of psychiatrists in Miami that accepts Medicare and Medicaid. Patients probably wait months to see him. The Miami Herald makes him look like a criminal. However, think about the majority of his colleagues who only see patients who can pay $200 or more out of pocket per visit. Dr. Mendez-Villamil is probably a hero, and if he writes 100,000 prescriptions per year this should be seen not as a crime, but a sign of a broken system.

The reason why so many psychiatrists stopped taking insurance, and the reason why those psychiatrist who accept insurance cram patients into 10 minute visits, is because the reimbursement rate from insurers is ridiculously low. Many psychiatrists realized that accepting insurance just didn’t make sense.

The same thing is happening right now in primary care. More primary care physicians have stopped taking new Medicare or Medicaid patients, or any insurance altogether. Some have even gone beyond cash only, and started “concierge” practices which charge patients a retainer fee in exchange for easy access to their primary care doctor.

Health care reform has focused on how to cover the uninsured and how to pay for this, but it has not focused on how to change the current reimbursement system that rewards “proceduralists” and punishes “congnitivists.” If health legislation that covers the uninsured does eventually pass without addressing this fundamental crack in our health care system, there will likely be no primary care physicians to see all these newly insured patients.

The few primary care physicians that do accept the newly insured will likely have limited access and see more patients in less time – like the good Dr. Mendez-Villamil. Whereas the typical psychiatric patient might be on 3-4 medications, the typical Medicaid and Medicare patient is on a great deal more medications.

Primary care physicians, get your pens ready. 100,000 prescriptions a year will seem like nothing.

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

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  • http://www.marinamartin.com Marina Martin

    Many of these medications cannot have refillable prescriptions, so every single patient would need a new prescription each month for each medication. 100,000 prescriptions annually for a psychiatrist is like 8,300 prescriptions annually for an endocrinologist who can write one RX for insulin or blood pressure medication and have it last all year.

  • Pk

    I have a friend with Bipolar. She sees her psychiatrist once a month ..she is never given refills, so her script is written each month. Her psych changes her meds almost monthly (and they wonder why they can’t get control of her bipolar that was under control before she started with this psych, when previous psych Rx’d a med and gave it a 3 month trial before changing ..which they rarely did)
    This psych sees a lot of medicare/medicaid (my friend is one) and does the 10 minute visit thing.
    (previous psych had 20 min appts not 10)

    It happens, whether or not it should is a whole nother story!

  • Greg

    Great post. As a primary care doc myself, I’ve had great difficulty getting medicaid patients in to see psychiatrists, because so few accept public insurance. Medicare patients have it a little easier, but it’s getting difficult for them to see psychiatrists as well.

    In IL, psychiatrists who take medicaid get about $45 for an hour of therapy, which is obviously a lot less than their $150+/hour fee they can command from cash patients without difficulty. This $45 is before taxes (say 25%), and doesn’t include paying their secretary (maybe $10/hour), and their expenses like rent, heating, etc (maybe $7-10/hour), so their actual fee for an hour of psychotherapy from medicaid is around $10-12 per hour.

    Is it no surprise that psychiatrists don’t take medicaid patients? They’d make the same amount of money flipping burgers at McDonalds!

  • Anonymous

    If he writes 150 prescriptions per day and works 200 days per year, that multiplies to 30,000 prescriptions per year, not 100,000 prescriptions per year.

  • http://drpullen.com Edward Pullen MD

    I practice in Puyallup, WA and we have similar access issues to getting patients into a psychiatrist. Same story, none get psychotherapy from psychiatrists, and many get medication management from psychiatric prescribing nurse practitioners. Most though get their psych medications from their family physician. This is not because we feel we are the best qualified, but rather because there is really no other choice. We do a pretty good job but would love to send many of these patients to psychiatry. Most psychiatrists will not see these government insured patients, so either we do our best at managing their meds, or they go without. My guess is that this psychiatrist running a “patient mill” in Miami is providing a lot better care than these patients would get if he was not seeing them.

  • JustADoc

    Depending on what counts as writing a prescription, 100K does actually seems low.

    If each refill counts as a new script than I write over 200 scripts a year for a single patient in some cases: Metformin, lisinopril, glucotrol, HCTZ, simvastatin, Advair, Spiriva, Albuterol, Metroprolol, Plavix, flonase, claritin, ranitidine, neurontin, escitolapram every month for 12 months then a few short term courses of something.

    A doc with a majority geriatrics practice probably averages 7-8 drugs/pt/month. 3000 pt. panel *8 drugs*12 months=284,000 scripts

  • ninguem

    Always looks suspicious to be an outlier like that, but the number alone does not necessarily mean it’s bad practice.

    It’s always possible, he really does work like a dog, really is seeing these patients, really is providing reasonable care, and really is billing appropriately.

    First thing that comes to mind, is whether he’s billing these short visits accordingly, or if he’s billing them as some long extended consultation.

    As pointed out, the alternative to him, for many of these patients is a visit to a nonphysician, or nothing at all.

  • Meryl Steinberg

    I’m speechless. But so much of what I see going on in or besieged healthcare system leaves me speechless. It is good to read the comments and get differing perspectives. I’m not a fan of drugs, yet know there are situations where they are extremely vital and helpful. 10 minute appointments couldn’t possibly do any good sorting those situations out. Yet is sounds like the best that can be provided. Sad.

  • G.L. Vazquez MD

    Part of this Doctor’s problem is due to the geographical location of his practice.Miami is the medicaid fraud capital of America.Just a few days ago a man was arrested for bilking the government out of 55 million dollars over a two year period.I am always amazed at how incompetent the government is at detecting fraud.

  • Manalive

    An elderly couple once asked me for refills for both of their meds – even thogh the visit was supposed to be just for him. He took five medicines; she, six. (Most of the prescriptions were prescribed by specialists who always seem to be inaccessible for necessary refills.) The wife instructed me that for each medicine there was to be a two week prescription for the local pharmacy; a ninety day prescription to mail away; and a thirty day prescription to take to their vacation pharmacy in Florida.
    As I dashed off the thirty-third prescription, the wife growled, “You didn’t put the dates on them, did you?”

  • Primary Care Internist

    I think we, the taxpayers, likewise should have the ability to halt salaries to politicians while their multiple payoffs by lobbyists are investigated too. That includes King Obama and his selection as HHS secretary Sebelius, who was chief lobbyist for the Kansas trial lawyers’ group.

    Whether or not Dr. Mendez’ practice is unethical or somehow improper, if he has patients then he is doing something right. And he should be innocent until proven guilty. If I were him, I’d make it my life mission to expose grassley and his colleagues for the hypocritical non-productive frauds that they are.

    I completely understand how a busy psychiatrist, or internist with a busy geriatric practice, could be writing 8-10 meds per patient per visit. If each cannot be refilled, the numbers don’t seem that crazy.

    And yes it is very common for my patients to ask for rxs of their celexa, complex insulin regimens, and even amiodarone, because they can’t get in to see their psychiatrist, endocrinologist, or cardiologist in a timely fashion. I’m sure that’s by design, as the latter do not much care for writing prescriptions for the local pharmacy, the snowbird patient, and MEDCO for every f***ing medication – leave that to the sucker PCP.

  • guy

    you guys should be happy that he takes medicaid and medicare and is a psychiatrist. I’m in dallas and i don’t believe we have a psychiatrist in the metroplex who takes medicaid and medicare. I agree that he probably don’t have to work as fast as he can but yeah miami herald run him off then you can be like here and have no one. I’m not in the country either; this is the metroplex with over 6 million people

  • teach

    As an individual, whose prior background is in mental health case management, I would state that the psychiatrist is employed by a nonprofit organization. The NGO is able to take Medicare and Medicaid due to their ability to raise money, and obtain contracts from county and city resources (court ordered from divorce cases, DUI, etc.). These doctors are usually paid a very nice salary, and write a number of prescriptions, due to their case managers are able to complete the marketing transaction for the agency. During my graduate school days, I worked at an elementary school where the therapists would demand that children obtain medication from a certain doctor or the principal would expel the student.

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