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