"Why don't you lie on the couch and tell me what's going
If you think this is how an appointment with a psychiatrist
might begin, think again. These days only 10 percent of the
nation's 50,000 psychiatrists actually talk to patients in the way
Sigmund Freud popularized therapy according to the American
Psychiatric Association. Psychiatrists who practice both
psychotherapy (talk sessions) and psychopharmacology (prescribing
medication) are a dying breed.
Instead, the norm that's dictated by insurance reimbursement
payments is that psychiatrists stick to 15-minute medication checks
-- insurers pay more for those. A psychiatrist may see 25 to 30
patients per day and simply ask if everything is going well while
they write a refill.
Meanwhile, a patient's therapy, if they're lucky enough to have
therapy, is handled by a psychologist or licensed clinical social
worker, often not even within the same practice as the
psychiatrist, making coordinated care difficult. Today's
psychiatrists know little about their patient's personal lives, a
stark contrast from the lay-on-the-couch-era decades before.
"The real change came about roughly between 10 and 15 years ago
with the Prozac revolution. We had more antidepressants and more
meds that supposedly were more effective," says Dr. David Reiss, a
San Diego-based psychiatrist.
While plenty of patients do so well on meds that they don't need
therapy, studies show the majority of patients do best with both
talk therapy. But psychiatrists are trapped in a system of
insurance incentives that discourages such integrated care.
Talk simply doesn't pay as much. "Which makes it impossible to
keep track of patients as 'people' as opposed to a collection of
symptomatology to be medicated," says Reiss.
Going where the money is
If psychiatrists wanted to pay the bills, they had to move with
"The psychiatry field has experienced an explosion in the use of
prescription meds. Ironically, and according to an MD in my state,
doctors can't afford to go into psychiatry because of insurance
reimbursement. He claimed it is the lowest paying field for doctors
and, with the cost of additional medical school for specialization,
it isn't worth it," says Pandora MacLean-Hoover, a Licensed
Independent Clinical Social Worker in Newburyport, Mass.
According to the U.S. Bureau of Labor and Statistics a
psychiatrist's mean annual income in 2011 was $174,170, compared to
a surgeon's at $184,650 and a dentist's at $241,100. Worse, the
2011 average psychologist's salary was $73,090.
Most shrinks used to treat 50 patients in once or twice weekly
talk therapy sessions of 45 to 60 minutes. Now, they treat 1,000
patients in mostly 15-minute increments for prescription refills
and tweaks to medication, explains Reiss Where once they delved
into patient's psyches with the skill and finesse of a trained mind
master, they now regularly pull out the prescription pad and mix
antidepressant cocktails like a chemist.
"Training programs by and large don't really even teach
psychotherapy anymore," says Reiss about up-and-coming
Insurance company reimbursement rates and health plans that
discourage talk therapy are mostly to blame. Although Reiss says
psychiatrists are not blameless: Greed and co-dependence on the
newer paradigm plays a role. A psychiatrist can earn $150 for three
15-minute medication visits compared with $90 for a 45-minute talk
session. You do the math.
"Consequently, mental health professionals have arguably the
worst reimbursements in health care, and many are leaving the field
or working outside of the health care insurance system," says Ivan
J. Miller, a Colorado-based psychologist and mental health reform
Worse, decades ago, psychiatrists saw patients three to four
times before they came up with a carefully plotted diagnosis and
treatment plan: depression, bipolar disorder or anxiety, for
example. But insurers now won't reimburse treatment without a
diagnosis, so today doctors make a difficult diagnosis within the
first 45-minute appointment.
Crunching the numbers
As part of The Task Force on Managed Care and Healthcare Policy,
Gordon Herz examined billing service information, Medicare
reimbursement schedules, and
surveys in order to
track 20 years of psychotherapy reimbursement
. He compared what insurance companies call "usual and customary
rates (UCR)," with the "real usual and customary rates" that
providers charge in communities. In most states, insurance
companies have such wide latitude in determining their own UCR that
the term merely means whatever the insurance company is willing to
And it's not so rosy for therapists at the Masters level either
-- marriage, family and child counselors and licensed clinical
social workers fare even worse.
"In 2010, Blue Cross Blue Shield of MA collapsed our
reimbursement rate to the lowest, which coincided with the cheapest
plan. The company did this despite maintaining tiered premiums for
their various offerings," says MacLean-Hoover. So while
policyholders continued to pay for these health plans, believing
the higher rates provided better coverage, psychotherapists no
longer received the higher reimbursement rates.
Indeed, spending on outpatient mental health has been flat or
declining at a time that parity laws suggest mental health services
should be more accessible and therefore increasing, says a 2009
report titled "
Trends in Mental Health Cost Growth
" in the journal
"I refuse to do med visits because they do not treat anyone's
psychological problems," says Dr. Carole Lieberman, a
California-based psychiatrist and author. "Medications are only
band-aids while the patient is supposed to be undergoing weekly
psychotherapy to get at the root of their problem. Far too many
psychiatrists have simply gone against what they know is best for
the patient and acceded to med visits in order to be able to pay
their mortgage and other living expenses. This is what's causing
the failure of our mental health system and the increase in
insufficiently treated patients."
The future of psychiatry
The problem is clearly multi-layered and, with violent incidents
becoming a topic of national mental health fodder, the system seems
"In terms of any individual incident I don't know if it could
have been prevented, but if you look at the mental health system as
a whole, very few people become violent but [substandard mental
health care] could factor in some of them," says Reiss.
There's also the problem that mental health services are an easy
target for managed-care cost cutting. And there's a long-standing
stigma associated with having a mental illness. When managed care
mishandles treatment of a physical health problem, patients go to
their employers and complain about the insurance company. But when
the issue is a mental health problem, most employees keep
Reiss thinks that if anyone looks at the long-term costs they're
going to see it's not cost-effective to run mental health in this
country as it's currently operating.
But as long as people want the system to provide the cheapest
possible mental health care possible, nothing will change.
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