Low reimbursement rates. Administrative hassles. Inflexible treatment options. Psychiatrists have had to contend with managed care since the early 1990s and the system does not appear to be heading for a change anytime soon, despite recent headlines announcing the bankruptcy of Magellan Health Services Inc. and the U.S. Supreme Court's decision to uphold Kentucky's "any willing provider" law.
Frustrations with the current system persist, and psychiatrists who are able to do so have been voting with their feet. In the process, they are creating their own changes to the system.
In states such as New Jersey, there simply are not enough psychiatrists, especially child psychiatrists, willing to participate in networks, George F. Wilson, M.D., said in an interview with Psychiatric Times. Wilson is chair of psychiatry at Princeton HealthCare System, where he directs a large inpatient unit and an outpatient program. Consequently, most managed care plans have inadequate networks and patients have a hard time getting appointments.
According to Wilson, this reluctance is largely a result of the low rates paid by health plans and an abundance of patients who can afford to pay out-of-network costs or direct fee-for-service charges.
The D.C.-based Washington Psychiatric Society has found that most doctors either are fee-for-service only or stay on one panel as a hedge. The best insurance right now is Medicare. "They give us the least hassle and pay in a timely manner," James F. Dee, M.D., Pharm.D., the society's past president, told PT.
Like other psychiatrists in certain parts of the country, Dee has found that business has not been hurt since he opted out of managed care. "I'm still turning away five or six patients a day here," Dee stated.Others said no from the start.
"I have never signed up with them," Nancy T. Block, M.D., past president of the New Jersey Psychiatric Association, said of private health plans. Block does take Medicare patients, but only as a non-participating provider, so that the patient has most of the contact with the program.
"You do just as well and deal with less paperwork," Block explained to PT. Opting out does have consequences, however. If a managed behavioral health care organization does not have asufficient network, odds are that a person in crisis will not be able to see a psychiatrist unless the patient can afford to pay out of their own pocket. That then becomes an access issue.
"Unwittingly, as a component of the care episode keeps getting redefined for lack of resources, intended or not, over time you begin to redefine what the average treatment input is," Irvin (Sam) Muszynski, director of the American Psychiatric Association's Office of Health Care Systems & Financing, told PT. "And you just hope that the floor doesn't become the ceiling."
According to Block, there exists a philosophical disconnect between psychiatry as a service profession and the bottom-line orientation of managed care companies, which abide by the rules that regulate them but consider anything they can legally get away with as fair game.
"Our entire system is being undermined," Block said. Patients do not get enough physician time, and physicians are unable to focus on any given patient's care. As a result, patients become disgruntled, and a disgruntled patient is far more likely to sue a treating physician, whether or not the physician has made a mistake.
A continuing frustration for psychiatrists is being limited to a medication management role. When a patient is approved for one visit a month for 15 minutes, that is simply not enough to provide needed care. "We all believe there are a number of patients who will do much better if the psychiatrist can do the psychotherapy as well as the medication management. But there is almost no company now who will approve that kind of united treatment," stated Wilson.
Talk therapy has become the domain of a separate network of therapists who are usually master's level clinicians. With the low rates that psychiatrists are paid for their 15-minute med checks, "it is difficult to maintain communication between the practitioners," Wilson explained.
The result is a two-tiered system. On the one hand are patients who can afford to pay up-front or have a point-of-service plan. On the other hand are middle-income employees who can only afford an HMO plan and the split-treatment process.