The fiscal realities of health care are demoralizing

In New York, I worked for an organization called Project for Psychiatric Outreach to the Homeless (PPOH). It has a humble history: Over 20 years ago, a group of psychiatrists were sitting around and discussing the need for psychiatric services for the homeless. They decided to volunteer their time and skills to this population.

The organization grew and, for both administrative and financial reasons, eventually became part of another social service organization, CUCS. At this point, PPOH serves more formerly homeless individuals than people who are currently homeless.

PPOH is not a big outfit. By the time I left, there were about 12 full-time psychiatrists, several part-time and per diem psychiatrists, and a handful of psychiatric residents. As a group, we worked at nearly 60 sites in three boroughs of New York City.

The job is atypical in many ways. PPOH psychiatrists are paired with different social service agencies to provide psychiatric services. The rationale is that social service agencies often don’t have the resources to employ psychiatrists. Furthermore, these agencies often do not know how to provide the support and supervision to psychiatrists. What they do have, however, are patients who would benefit from psychiatric services, but the patients either cannot or will not visit a psychiatrist in a clinic or other typical setting.

Thus, PPOH brings psychiatrists to the patients.

Funding for PPOH differs from funding for “mainstream” psychiatric services. PPOH receives funding from state and city agencies (government money), grants (from organizations like Robin Hood and van Ameringen), and fees from the social service agencies themselves. These fees are usually lower than what it would cost to hire a per diem psychiatrist directly.

Because PPOH did not receive money from Medicaid, it did not have to follow Medicaid rules and regulations. (PPOH would not be able to fulfill its mission if it did accept Medicaid funds, as Medicaid has requirements that physicians see patients in a physical locations designated as clinics. This contradicts the organization’s mission. While at PPOH, I often saw patients on sidewalks under scaffolding, in their apartments, etc.)

I was one of the few psychiatrists in the group who worked with an agency who worked with Medicaid, though because of the nature of the program (an Assertive Community Treatment program; more on that later), the regulations had little effect on my actual clinical work. It did influence the documentation I had to provide.

PPOH does not have any contracts with insurance companies (as the target population often did not have traditional insurance), which also means that there were no negotiations about reimbursement rates or discussions about concessions to have access to the patients on an insurance panel.

Thus, I essentially had a job outside of the US healthcare system, which, in many ways, was appropriate: The population I worked with was also generally outside of the US healthcare system. Despite this, we often viewed ourselves as “hot spotters”, as a few of our patients often crossed into the US health care system through ERs and hospitals.

Because of this funding structure, I worked as a salaried employee. There were no productivity expectations or bonuses. While this arrangement can result in people slacking off, my boss chose his employees carefully to prevent this problem.

Psychiatrists who choose to work at PPOH, however, do not work there for the money. The median salary for a psychiatrist in New York is apparently $228,815. During my time at PPOH, over 90% of psychiatrists in New York earned more money than me.

(Yes, the specter of student loans continues to haunt me and, of course, it would be nice to make more money, but let’s be honest: I was earning enough money to live comfortably in New York. Not everyone who lives there can say that.)

In exchange, I had the time and opportunity to work with those who often do not receive care. Many of these individuals had significant psychiatric conditions that contributed to their lack of employment, homelessness, and poverty. I had more control over how often and how long I got to see patients. Patients had easier access to me and I had the flexibility in my schedule for urgent appointments.

The idealist in me finds the fiscal realities of health care demoralizing. I don’t like thinking about how economics affects the relationships I have with patients. I didn’t go into medicine to think about that stuff. However, I do firmly believe that physicians should have a basic understanding of their clinic or department budgets. Form follows function. And form follows funds.

Maria Yang is a psychiatrist who blogs at In White Ink.

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  • Anonymous

    Uh, this is America.  As you know, America does not care about poor people. American cares about the moneyed.  If you want to practice without regard to finances, you are in the wrong country.

    • Anonymous

      Wow…I think you should be occupying Wallstreet.

      • Anonymous

        I think I should be, too.

  • Anonymous

    If you read the book, ANATOMY OF AN EPIDEMIC, by Pulitzer Prize winning journalist Robert Whitaker, it totally belies this article’s false pretense that psychiatry helps anyone, especially the homeless who are trying to escape them already for having destroyed their lives.  Assertive Community Treatment is just a con job to FORCE very expensive psychiatry and lethal drugs on the poor and homeless instead of using the funds to provide housing, food, training and other essentials to end the problem.  The outrageous lie that such people are dangerous is a projection of the most dangerous, violent and fraudulent profession of all: psychiatry to justify their greed, power hunger and bogus status.  Anyone caught in the net of this horrific POGRAM is robbed of all democratic and other human rights and forever forced into outrageous mental, physcial and spiritual abuse by the mental death profession pretending those they abuse are the dangerous ones.  Needless to say, just being homeless like being abused and robbed of justice is very traumatic and will automatically earn one a bogus stigma from psychiatry to justify their fraudulent, lethal treatments at huge cost.  See critques of the psychiatric “bible,” the DSM whereby the white old boy network elite in bed with BIG PHARMA VOTE in their bogus labels without a shred of scientific or other evidence to prey on normal people experiencing life problems/crises, emotional or social distress, etc.  Speaking of OCCUPY WALL STREET, wake up America to this huge threat to everyone’s civil rights by the PSYCHIATRIC TOTALITARIAN POLICE OF SOCIAL CONTROL!!  Just as in Stalinist Russia and Nazi Germany, any protesters or challengers to the power elite are labelled “mentally ill” by these state shills and drugged, shocked into oblivion and early death at violent institutions with all violence is commited by psychopathic psychiatry in collusion with our “democratic” government, courts, police!