Managed care has brought some positives along with the well-publicized negatives. I worked for 20 years in the fee-for-service environment and loved the freedom, the non-intrusiveness by outside parties, not having to create treatment plans, easy billing and so on. I certainly do not agree with the bottom line justifying the denial of treatment or CEOs receiving large salaries. But fee-for-service also had its abuses, such as hospital stays being extended until the insurance ran out, the rapid spread of for-profit hospitals and, without oversight, the healthiest patients often received intense long-term treatment at the expense of patients with more severe disorders.
With the rise of managed care, we have seen fewer for-profit hospitals, the scaling back of inappropriately long hospitalizations and lower co-payments that have brought employees with lower incomes to psychiatrists at earlier stages of illness. Hopefully, the worst abuses of managed care are being dealt with, and the pendulum is slowly swinging back toward physicians and patients.
Comparing my practice in 1978 with 1998 and working approximately the same number of hours per week, I still found many differences (Figures).
The number of patients that I saw nearly tripled. This was mainly due to seeing patients less intensely and not seeing them for a shorter term. The number of referrals increased. Referral sources went from mostly physicians and other mental health care professionals to managed care companies now making many referrals. The patient gender ratio went from more female to more male. The number of sessions per patient per year reduced greatly. Surprisingly, the length of treatment had not changed that much, the major change was intensity. Diagnoses remained relatively the same, but the major change was the number of patients on medication for depression, anxiety and substance abuse. The age of my patients also increased. I believe this increase may reflect my own aging.
There are many factors that have contributed to the change in my practice patterns. As I get older and see how scientific knowledge has altered our view of the brain and mind during my career, I have become less dogmatic regarding what is best for the patient. I usually present the various options -- dynamic, cognitive, behavior and psychopharmacology -- and try to build more of a partnership in developing a treatment plan that fits the patient's needs, finances and time. Gone are the days of "Doctor knows best." I use more of an educational approach, including encouraging patients to read and use the Internet to learn about their disorders and medications. People are very busy these days and after getting to know the patient, I find they are often relieved that they do not have to come in so frequently. With less intense treatment, I find the use of the telephone increasingly important. My office number goes into my home on evenings and weekends, and there is very little abuse. I am not getting any more calls now than in the past, and I attribute it to patients being less dependent and more self-reliant.
With more patients in my caseload and seeing them less intensely, it is agreeable to take a few notes during the session with most patients actually seeming to appreciate it. Only the most paranoid patients ask how the notes will be used or decline. The reduced stigma of mental illness and managed care are two reasons, I believe, patients of lower socioeconomic status and males are more willing to see a psychiatrist. Improved medications and direct-to-consumer advertising -- good and bad -- of psychotropic medications result in patients being more open to the use of medications and using them more frequently.
In the '70s without managed care, I did my own billing. Today, private practice psychiatrists need support in running their practice, particularly in regard to billing. Over the years, I have had to make great changes in how I practice, some good and some not so good, i.e., paperwork and intrusion into the doctor-patient relationship. The good is the diversity of patients and that patients in general are less dependent and usually willing to take more responsibility for improving their own mental health. I feel my understanding of the brain and mind is better today than it had previously been. We now have better medications that are safer and have fewer side effects. I do not have to be as passive in the therapeutic session as when I first started my practice. Being more active in my interpretations and more of an educator as a therapist is rewarding. By seeing more patients and probably more disturbed ones, I am more relevant to society. Yes, despite and because of the many changes, I am enjoying the private practice of psychiatry as much today as I did 20 years ago.
One might ask why I am still enjoying practice with all the negative feelings that we hear toward the managed care industry. One has to look at the history of why managed care was instituted 10 years ago. Medical costs were going up twice the inflation rate and, unless something was done, we were most likely headed for a single-payer system, which certainly most clinicians did not want. Managed care was instituted rather suddenly with an attitude of "Take it or leave it" and with little input from practicing clinicians. This was perceived as arrogant and soon became very intrusive in the doctor-patient relationship, greatly increasing burdensome paperwork and lowering reimbursement rates. Over the years, managed care companies had to change or they would have had few psychiatrists remaining on their panels. In general, managed care companies today are less intrusive, are reducing paperwork and are raising reimbursement rates, and as they make these changes, it is easier for psychiatrists to work with them. Psychiatrists have also changed their practice patterns over the years, which I believe has very little to do with managed care. These changes are the results of a reduced stigma of mental illness, patients coming in earlier and patients being more compliant with treatment. We are having better treatment outcomes including better medications, which encourage patients to seek treatment. Successful research into our understanding of mental illness makes treatment more effective. We hospitalize less often and for shorter stays because we think it is better for the patient.