Going where the money isIf 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.
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 numbersAs 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.
"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 Health Affairs.
The future of psychiatryThe problem is clearly multi-layered and, with violent incidents becoming a topic of national mental health fodder, the system seems broken. "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 quiet.
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. More: Health insurance basics.