| As I discuss career options with a group of | | | | difference come from? Certainly not from |
| third year medical students, I imagine a | | | | supply and demand, as in my area it is much |
| marketing brochure for psychiatry residencies | | | | easier to see an orthopedist this week than |
| in a world of mental health parity: | | | | to see a psychiatrist within the next month. |
| | | | There must be other factors that affect the |
| The brain is undeniably the most complex | | | | perceived value of the services of a |
| organ of the human body. Beyond controlling | | | | psychiatrist. Does the lower reimbursement |
| virtually all body functions, the brain is | | | | reflect decades of poor negotiating? Are |
| the source of the mind, which is but an | | | | psychiatrists more likely to succumb to |
| ethereal concept, so hard to grasp that even | | | | modesty and self-effacement? Do |
| the language of mental theory requires | | | | psychiatrists have so great a level of job |
| methodical parsing. Treatments for diseases | | | | satisfaction that they don't worry about |
| of the mind and brain require the intricate | | | | money? I wonder if the difference reflects a |
| understanding of chemistry, physiology, and | | | | much larger problem-- that psychiatrists have |
| anatomy common to all branches of medicine, | | | | bought into a societal impression that mental |
| as well as the ability to step outside of | | | | health is less valuable than physical health. |
| oneself to objectively observe personality | | | | |
| and emotion. The psychiatrist must tolerate | | | | Support for this last concern can be found |
| the unsettling awareness of the mysterious | | | | when one looks at the funding of mental |
| relationship between mind and matter, and | | | | health services in general, and the tacit |
| must help others find their own answers to | | | | acceptance of the funding situation by |
| the mysteries of the human condition. The | | | | psychiatrists and other mental health |
| shortage of physicians willing to engage in | | | | caregivers. My insurer is required by |
| this area of study reflects the enormity of | | | | statute to provide coverage for mental health |
| the challenges. Some medical students become | | | | services up to about $2000 per year. This is |
| cardiovascular surgeons, the plumbers of | | | | the total amount provided for all services, |
| medicine. Others choose to nail bones | | | | and is not paid for any treatment deemed |
| together, taking pleasure in the simplicity | | | | 'residential'. On the other hand, there is |
| of hand tools. Still others find a good | | | | no limit on payment for orthopedic injuries. |
| living looking at see-through images of body | | | | The insured alcoholic is covered for the |
| parts; often a day or two after the images | | | | $1800 surgeon's fee for a fractured kneecap- |
| have been used for their intended purpose. | | | | and more for the incidental hospital bill and |
| These tasks pale in comparison to the labors | | | | the bills for physical therapy. If the |
| of understanding and treating diseases based | | | | alcoholic strikes his head, the radiologist |
| in the final frontiers of medical knowledge. | | | | receives $1200 to look at the MRI. And if he |
| No wonder that the masters of medicine-those | | | | abruptly stops drinking for a week, the |
| who work in the vast field of interventional | | | | hospital is paid tens of thousands of dollars |
| psychiatry-are so valued by society. | | | | to help him through withdrawal-- only to turn |
| | | | him out to drink again. Yet to treat the |
| The time has come for my transition from | | | | primary alcoholism, the insurer will |
| psychiatric residency to psychiatric | | | | pay…$2000. Unless the patient has been |
| practice. Not surprisingly, we graduates | | | | placed in a more effective residential |
| have encountered great demand for our | | | | treatment center, in which case there is no |
| services; the posting of resumes on internet | | | | payment at all. And if the patient has spent |
| boards results in a slew of telephone calls | | | | $2000 for treatment of depression earlier in |
| from eager recruiters. For my younger | | | | the year, the insurer will continue to pay |
| colleagues the prospect of six-figure incomes | | | | for kneecap fractures and MRIs, but not for |
| suggests reward, at last, for years of work | | | | treatment of the underlying cause of these |
| and debt. Most job offers come from | | | | injuries-alcoholism. |
| healthcare systems looking for someone to | | | | |
| prescribe medication as counterpoint to their | | | | There is no shortage of evidence for the |
| bevy of lesser-paid psychotherapists. Under | | | | notion that society places a low value on the |
| the guarantee of income and benefits lies the | | | | treatment of mental illness. My insurer will |
| expectation of productivity. This | | | | pay $70,000 or more for cardiac bypass to |
| productivity is not measured by patient | | | | reduce a person's risk of a heart attack, but |
| satisfaction, symptom improvement, or reduced | | | | only $2000 per year for treatment of the same |
| morbidity. Rather the name of the game is | | | | person's depression, to reduce risk of |
| the RVU, and the way to get more RVUs is to | | | | suicide. The narcotic addict is allowed |
| see more patients in whatever time is | | | | $2000 for treatment of heroin addiction, vs. |
| available. While many residents long for the | | | | hundreds of thousands of dollars for a |
| independence to practice as they see fit, | | | | secondary HIV infection. Our insurers face |
| their debt loads require more practical | | | | no uprising when they decide that an insured |
| approaches. Concerns over production and | | | | businessman deserves a new ACL to allow a bit |
| practice limitations pale in comparison to | | | | more knee stability, yet an unfortunate |
| long-delayed plans to start families and buy | | | | computer operator who develops schizophrenia |
| houses. | | | | deserves less than one-tenth as much to |
| | | | prevent delusions and hallucinations. |
| For my part, I am grateful for the | | | | |
| opportunity to earn good money in the service | | | | The relatively low payments received by |
| of a challenging and rewarding career. But I | | | | psychiatrists can be blamed to some extent on |
| am also aware of the striking difference | | | | psychiatrists themselves. They accept their |
| between the salaries of psychiatrists and the | | | | own devaluation when they sign for lower |
| salaries of many other physicians. As a | | | | salaries or when they accept limitations on |
| former practitioner of one of medicine's more | | | | their ability to practice psychotherapy. |
| lucrative specialties, I find myself | | | | They allow administrators and others without |
| comparing my apparent value now with my value | | | | medical training to dictate treatment plans. |
| then. Why is my work now worth less than | | | | And they follow the Pied Piper of pill |
| half as much as my work as an | | | | pushing, happy to become simple prescribers, |
| anesthesiologist? | | | | even as state legislatures grant similar |
| | | | privileges to those with minimal medical |
| At the end of a night in the crisis service | | | | qualifications. I am reminded of the late |
| last week I walked past a group of patients | | | | 1980's when anesthesia was becoming perceived |
| huddled in the cold, waiting for the doors of | | | | as a technical trade, and was challenged by |
| the walk-in clinic to open. As I looked at | | | | the expanding statutory roles of nurse |
| their tired faces, I realized the desperation | | | | anesthetists. Rather than narrowing |
| they must feel to leave homes or homeless | | | | anesthesiology, the answer to devaluation was |
| shelters at such a cold and early hour, and | | | | found by moving into critical care and pain |
| make the trek to the clinic by foot or by | | | | medicine and asserting the roles of |
| bus. Their pains were certainly as great as | | | | anesthesiologists as physicians. Similarly, |
| the pains of any of my patients presenting | | | | cardiologists did themselves and their |
| for surgery. But for some reason there is | | | | patients well when they laid claim to |
| less outrage over their lack of care than | | | | angioplasty, and called themselves |
| would be the case for a group of patients | | | | 'interventional'. The new technology brought |
| with untreated diabetes, appendicitis, or | | | | public respect and money, which then yielded |
| heart disease standing outside a hospital. I | | | | an explosion of new treatments. Likewise, at |
| realized that like many in society, I had | | | | some point radiologists decided that they |
| unwittingly accepted the scene before me as | | | | could stick needles into kidneys as |
| adequate care for the mentally ill. | | | | accurately as any surgeon, and soon |
| | | | radiologists were awash in black ink, and |
| The RBRVS, or resource-based relative value | | | | learning to stick needles pretty much |
| scale, was instituted by Medicare in 1992 in | | | | anywhere. I don't know what the parallel |
| an attempt to standardize payments for | | | | path for psychiatrists will be, but it is |
| physician services. Relative value units, or | | | | vital that as insights develop into brain |
| RVU's, are assigned to physician services | | | | function, psychiatrists lay claim to them, |
| based on three main factors: physician work, | | | | grasp them, and never let them go. There is |
| practice expenses, and the cost of liability | | | | nothing like a brain procedure to grab |
| insurance. Physician work is determined by | | | | society's interest and respect. In fact, I |
| several factors including time required for | | | | posit that the simple adoption of the term |
| the service, the technical skill and physical | | | | 'Interventional Psychiatry' would increase |
| effort, the mental effort and judgment, and | | | | the funding of psychiatrists and psychiatric |
| the amount of stress experienced by the | | | | research by 20%. |
| physician due to the risk to the patient. To | | | | |
| arrive at the 'fair value' of services, the | | | | The low priority of mental health services to |
| number of relative value units is multiplied | | | | society is, of course, a complex issue. |
| by a universal dollar value, and adjusted | | | | Stigma, lack of lobbying resources, and |
| slightly for practice location according to | | | | denial of the impact of mental illness |
| regional cost of living indices. | | | | certainly play roles in the lack of public |
| | | | interest and investment in mental health. |
| In theory, this approach to payment provides | | | | Resources are thin for the unemployed and |
| a level playing field for physicians. | | | | uninsured mentally ill, and the field of |
| Payments for a cholecystectomy, for example, | | | | psychiatry deserves kudos for attempting to |
| reflect the fortitude one must have to cut | | | | meet the needs of this population in return |
| into someone's body and the time required for | | | | for little financial gain. But for patients |
| surgery and postoperative care. Payments for | | | | with resources, we must recognize and |
| neonatal critical care reflect the higher | | | | advocate that mental health care is as |
| level of stress that comes with working in an | | | | important as treatment for a torn ACL, and |
| alarm-filled environment, as well as the need | | | | deserves equitable reimbursement. The |
| for proficient technical skills. Medicare | | | | abilities to laugh, to work, and to love are |
| strictly adheres to this formula, but in the | | | | as vital as the ability to return to beach |
| world of private insurance some physicians' | | | | volleyball. Psychiatrists must realize that |
| relative value units are more valuable than | | | | at some point, expectations of relatively low |
| others. In my region, for example, Medicare | | | | reimbursements and medical standing become |
| has decided that the relative value of a unit | | | | self-fulfilling prophecies, as our capitalist |
| of physician work is about $38. The largest | | | | society tends to value those most who value |
| third-party payer in the area will pay | | | | themselves. The correction of societal bias |
| psychiatrists, pediatricians, or family | | | | and the resultant devaluation of our services |
| physicians about $50 per value unit. But | | | | will require constant efforts to educate, |
| orthopedists and radiologists, or podiatrists | | | | negotiate, and assert the value of mental |
| providing orthopedic services, are paid $100 | | | | health care in a healthy society. And as |
| per value unit. | | | | self-serving as it may be, psychiatrists, as |
| | | | the voices, faces, and business |
| Given that the relative value of a service | | | | representatives of mental health, will raise |
| has been predetermined, what accounts for the | | | | the status and treatment of their patients as |
| difference in payment? If not due to stress, | | | | they work to raise the scientific, and yes, |
| physical or mental effort, risk, technical | | | | economic, status of themselves as physicians. |
| proficiency, or practice cost, where does the | | | | |