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Talk Is Cheap: How Insurance Changed The Face Of Psychiatry

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 psychiatrists.

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 advocate.

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 Psychotherapy Finance 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 reimburse.

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.

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