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October 16, 2009
Reforming the 'doctorless' health system
It’s old news by now that the Senate Finance Committee has approved legislation that would attempt to reform our health care system. The major features of the revised Baucus bill would include mandatory health insurance for nearly all Americans, taxes on “Cadillac” insurance plans, the creation of non-profit insurance cooperatives, special taxes on drug/ medical device makers as well as insurance companies, and elimination of “pre-existing condition” exclusions.
Republicans promise to make the bill’s passage through the Senate difficult, and hardline Democrats still have their sights set on a public insurance option. We can continue, therefore, to expect the negotiations to play out with the subtlety and finesse of a prize fight.
The vested lobby groups are certainly swinging harder than ever. The Washington Post revealed that the health sector has been spending money at a rate of $1.5 million a day (yes, a day) in an attempt to influence health care reform legislation. Really, who turns enough profit to invest that sort of money in politics? Apparently the biggest spenders were drug manufacturers, hospitals, and insurance groups. And if $1.5 million a day weren’t enough to buy political favor, the insurance industry also launched an ambush attack the day before the vote by releasing a report that suggested that reform could potentially increase insurance premiums. The Democrats labelled the attack scaremongering, and Obama said it confirmed that the legislation was heading in the right direction.
There’s a lot of talk about the vested interests of pharmaceutical manufacturers and insurance companies (rightly so), but what about the system’s users and providers? Where have the doctors and patients gone? Maybe I’m self-interested because I am a doctor and I work with patients, but I’d like know—while congressional committees are debating over insurance exchanges and gold-plated policies—where are the doctors and patients who collaborate on treatment plans?
Dr. Arnold Relman, writing in the New England Journal of Medicine, makes the obvious, but somehow overlooked, point that it’s doctors that make most decisions about the use of medical resources—the same doctors that have a strong financial incentive to maximize elective services and utilize new, expensive technology. This begs the question: how will the proposed legislation control inflationary health care costs as long as doctors are incentivized to use more services and resources? The existing system has encouraged a creeping entrepreneurial ethic into medicine. Physicians who work in hospital systems are rewarded for doing procedures and tests, and the yield from Medicare/Medicaid is comparatively higher for inpatient vs. Outpatient care. In many instances these programs don’t pay for outpatient wellness visits—only sick ones. Meanwhile, primary care providers may see 41 patients a day and receive little to no reimbursement for time spent educating patients about preventative health care. Likewise, some patients are happy to report to the emergency department, rather than a primary care provider, with an earache or head lice. (Yes, I’ve personally witnessed that). What will incentivize those people to purchase health insurance? A $750 annual penalty, I don’t think so (and then there is the “hardship” clause that would exempt people who are likely to be using the emergency department as primary care).
These are not just administrative issues; this is about the health care culture in our country. Surely cultural change must be pivotal in any real overhaul of our health care system, so shouldn’t the vested interests of doctors and patients—not only drug and insurance companies—be central to the debate?
Robin Stone, M.D.
Insight Psychiatry
13123 Rosedale Hill Ave.
Huntersville, NC 28078
704-948-3810
Further reading:
Eggen, D 2009 At $1.5 million a day, health sector lobbying far outpaces oil and gas, The Washington Post.
Relman, AD 2009 Doctors as the key to health care reform, New England Journal of Medicine, 24 September, vol.361, no. 13.
October 1, 2009
Reflections on Psychotherapy
Health care reform highlights more than the changing nature of medicine—it highlights that social change is underpinned by ideologies that vie against each other in a competitive marketplace of ideas and values. I explored that topic in my last blog. In this blog, I reflect on the transformation of psychotherapy in psychiatric practice. I want to begin by acknowledging that sometimes change manifests as a schism between old and new—a sudden break from the past that throws our modes of acting and thinking into disarray. But revolutionary change is extremely rare—there are usually too many stakeholders invested in the existing order of things. The current health care debate is a good example. More often than not, then, change is evolutionary or environmental—we change because we adapt or because the constant drip, drip, drip of external factors wares us into a different form. In the case of gradual transformation it’s only through reflection that we can make sense of the forces acting on us.
From its inception in the late nineteenth century until very recent times, psychotherapy dominated psychiatry. As a therapeutic model it eloquently combines and addresses the biological, psychological, and social dimensions of illness. It powerfully acknowledges the multi-directional nexus between how we think, feel, and act. And yet, psychotherapy has always been somewhat clouded in conjecture. I think that some of that can be attributed to its popularization in the twentieth century which resulted in entertaining, but inaccurate, stereotypes. Say the word “psychotherapy” and many people will envisage the peculiar dynamic of a patient reclining supine as he relates childhood memories to a therapist who sits behind him, out of view, scribbling notes. In a more recent stereotype, the analyst assumes a social accessory role similar to that of the tennis coach, Pilates instructor, or personal trainer. When the psychiatric profession is so often reduced to a caricature, it’s easy to appreciate why the average person could be intimidated by it.
But since the 1990s the fog has thickened around psychotherapy within the psychiatry profession itself. A national survey of outpatient medical practices from 1996 to 2005 revealed that psychotherapy and pharmacotherapy in psychiatry are increasingly split:
The investigators surveyed 14,108 visits to psychiatrists involving a psychiatric diagnosis. The percentage of visits with at least 30 minutes of psychotherapy decreased significantly over 10 years from 44 percent to 29 percent. For patients with private insurance, the decline was significant (from 50 percent to 25 percent), but not for those in publicly funded programs, where the initial percentage was low (Medicare, from 32 percent to 21 percent; Medicaid, from 22 percent to 13 percent). The percentage was highest among self-paying patients and did not change significantly (from 55 percent to 59 percent). In HMOs, the percentage of visits with psychotherapy decreased significantly to a remarkable degree (from 23 percent to 5 percent) (Dubovsky 2008).
In short, psychotherapy is being eroded from psychiatric practice and, upon reflection, there are a number of environmental causes. The most significant factor is an economic one. Psychiatrists who work within managed care programs administered by insurance companies are discouraged from combining psychotherapy with pharmacotherapy. They’re under pressure to see a large number of patients and work within a system that rewards short consultations. The same study revealed that ‘third-party reimbursement to psychiatrists is 41 percent less for one 45-minute psychotherapy session than for three 15-minute "med checks."’ (Dubovsky 2008).
At the same time, there’s been a paradigm shift in psychiatry that focuses on mental illness as a physiological disease—a biological imbalance that can be chemically corrected. As a consequence, there’s stronger emphasis on drugs in psychiatry—a trend which finds favor with pharmaceutical companies, cost-conscious insurers, and patients looking for fast relief. Anti-depressants are now the most commonly prescribed drug in the US. Indeed, psychotropic drugs have revolutionized psychiatry by strengthening the biological component of the biopsychosocial model—but I’ve also seen, over and over, that pharmacotherapy is rarely a complete solution. People are complicated—more complicated than chemistry alone can account for. They ultimately seek to be understood and to understand themselves, not just to be promised that their neurotransmitters will be set right with a pill. It’s the relationship that heals, and the correct formulation of diagnosis and treatment is powerful in, and of, itself.
Think of someone who’s never understood why they think, behave, or feel the way they do, and has suffered greatly most of their life. For example, they may have experienced emotional problems, anxiety, interpersonal difficulties, or failed career aspirations. Now interject another person who’s trained to illuminate reasons—taking into account the biological, social, psychological aspects of their circumstances—in a safe, non-judgmental arena, and at the right point in a patient’s life. The key to improved mental health lies in not only alleviating a patient’s symptoms, but in helping them to understand and address the underlying causes of those symptoms. When a patient improves through insight and understanding, they gain a much better sense of control over their disorder. The result is that they experience a more positive prognosis, which might be more aptly described as a better life.
The pendulum is swinging back as mounting clinical research demonstrates that psychotherapy is more effective than drugs alone in treating many mental disorders. (Refer to the American Psychiatric Foundation for further information about clinical findings). The positive effects of psychotherapy can be measured not only by symptom relief, relapse reduction, and patient wellbeing, but by physiological changes in the brain. They key here is that the growing proof for psychotherapy not only appeals to the medical and scientific community, but that it also piques the interest of penny-wise insurance companies!
Robin Stone, M.D.
Insight Psychiatry
13123 Rosedale Hill Ave.
Huntersville, NC 28078
704-948-3810
References & further reading:
American Psychiatric Foundation 2008 Psychotherapy basics, Mental HealthWorks.
Mojtabai, R & Olfson, M 2008 National trends in psychotherapy by office-based psychiatrists, Archives of General Psychiatry, vol. 65, no. 8.
Dubovsky, S 2008 Psychiatric practice: a march from the brainless to the mindless?, Journal Watch Psychiatry, September 15.
