Friday, August 31, 2012

Update on operating in the trenches of health care

This is from an email I recently sent to a colleague. It also relates to the comment on my last blog by Dr. Dawson, and the new assembly line psychiatry. I can't begin to count the number of patients of mine who complain that they've been to other psychiatrists who never talked to them, spent 10 mins and prescribed drugs. This, in my view, results in gross overtreatment with medications, poor decision-making regarding medication management, poor patient outcomes, lack of patient participation in treatment decision-making, as well as patient and family dissatisfaction. I don't think it's possible to properly evaluate a patient in that amount of time. If the patient is so stable they don't really need an evaluation, just a prescription, then they don't need a psychiatrist, their primary care doctor can do that.

There is now a terrible shortage of psychiatrists, and it will reach truly crisis proportions in the next 10 years as the aging workforce retires or dies. This could be changed by reforming practice to make it more gratifying (and effective), increasing compensation (psychiatry is the third-lowest paid specialty, after pediatrics and primary care (family practice and general internal medicine), and involving patients and families more in decision-making. Unfortunately, the mistakes made in the past, such as separating psychotherapy (now provided by therapists and counselors from a wide variety of backgrounds and competencies)  from medication management (by psychiatrists), with another: replacing psychiatrists with "mid-level" providers, such as nurse practitioners and physicians assistants. The result is simply an ongoing degradation of psychiatric practice and care and outcomes, and an increasing shortage of competent and well-trained staff.

But I digress. Here's the email, responding to a question about how things were going in my post-NIH world.

All is good here, working my butt off in practice and still working to establish a new model of scientifically based treatment in the next year. As with most things, it turned out to be more complex and difficult than initially imagined, but there is tremendous enthusiasm among health care professionals and even more so among patients and their families, who are very very frustrated with the current state of affairs. So the time is still ripe, if not riper than ever. Toughest parts are going to be staffing, especially with docs, and financing and the business model, especially with the continuing near-depression we are still in. 

I have to say, working where I do, in downtown St. Paul, I treat a lot of people who have lost everything, when they had everything in 2007. Their jobs, homes, families, self-esteem, health. Everything. Experiencing the human face of this terrible economic crime gives a whole different perspective. And Minnesota is in better shape than most places, and has arguably the best safety net in the country. So I can't imagine what it's like in Arizona, Texas or Florida. At any rate, I'm fortunate to work (part-time) for a company that essentially subsidizes psychiatric care for the poor. Again, that is not the norm around the country. Minnesota has a law requiring health care organizations to be non-profit, which makes all the difference in the world. 

The other part of the health care world I've had the pleasure of experiencing is the horrible nature of the health insurance industry, and the games they play to deny payment for care they are obligated to, by putting up lots of bureaucratic barriers, knowing that many patients or doctors will give up. Yesterday, for example, I was trying to induct Suboxone treatment for a patient in the clinic (who was in withdrawal) and the insurance company wouldn't pay for the Suboxone without a prior authorization (one of the most common and frustrating barriers.) So the patient had to go to the pharmacy, get the coverage denied before we could initiate the PA request, then the nurse went through the hoops, spending 30 mins, but the company wouldn't even give an answer for 24 hours. So the pt had to leave without the Suboxone, use more illicit opioids until we got the approval, then return to the clinic again in withdrawal, or start at home. And you can't get a PA in advance, it has to be denied first. So the patient spent an entire afternoon waiting around for the PA, the nurse spent 30 mins on the phone, and I spent about 30 mins of my time trying to make this work (none of which we got paid for). And people wonder why our system costs so much. And this didn't make any sense at all anyway, all they needed to know was that the indication was opioid dependence. 


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