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Talk Is Cheap: How Insurance Changed The Face Of Psychiatry

"Why don't you lie on the couch and tell me what's going on?"

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 medication and 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 times.

"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.

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