Talk Doesn’t Pay


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“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 medicationand 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.

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.