In theory, this approach to payment provides a level playing field for physicians. Payments for a cholecystectomy, for example, reflect the fortitude one must have to cut into someone's body and the time required for surgery and postoperative care. Payments for neonatal critical care reflect the higher level of stress that comes with working in an alarm-filled environment as well as the need for proficient technical skills. Medicare strictly adheres to this formula, but in the world of private insurance, some physicians' RVUs are more valuable than others. In my region, for example, Medicare has decided that the relative value of a unit of physician work is about $38. The largest third-party payer in the area pays psychiatrists, pediatricians, and family physicians about $50 per value unit, but orthopedists, radiologists, and podiatrists providing orthopedic services are paid $100 per value unit.
Given that the relative value of a service has been predetermined, what accounts for the difference in payment? If not stress, physical or mental effort, risk, technical proficiency, or practice cost, what is the source of the difference? It certainly is not from supply and demand; in my area, it is much easier to see an orthopedist this week than to see a psychiatrist within the next month. There must be other factors that affect the perceived value of the services of a psychiatrist. Does the lower reimbursement reflect decades of poor negotiating? Are psychiatrists more likely to succumb to modesty and self-effacement? Do psychiatrists have so great a level of job satisfaction that they don't worry about money? I wonder if the difference reflects a much larger problem—that psychiatrists have bought into the societal attitude that mental health is less valuable than physical health.
Support for this last concern can be found in the funding of mental health services in general and the tacit acceptance of the funding situation by psychiatrists and other mental health caregivers. My insurer is required by statute to provide coverage for mental health services up to about $2000 per year. This is the total amount provided for all services and is not paid for any treatment deemed residential. On the other hand, there is no limit on payment for orthopedic injuries.
The insured alcoholic is covered for the $1800 surgeon's fee for a fractured kneecap—and more for the incidental hospital bill and bills for physical therapy. If the alcoholic strikes his head, the radiologist receives $1200 to look at the MRI. And if the patient abruptly stops drinking for a week, the hospital gets tens of thousands of dollars to help him through withdrawal, even though they turn him out to drink again. Yet to treat the primary problem—alcoholism—the insurer will pay $2000. If the patient is placed in a more effective residential treatment center, there is no payment at all. And if the patient has spent $2000 for treatment of depression earlier in the year, the insurer will continue to pay for kneecap fractures and MRIs, but not for treatment of the underlying cause of these injuries—alcoholism.
There is no shortage of evidence for the notion that society places a low value on the treatment of mental illness. My insurer will pay $70,000 or more for cardiac bypass to reduce a person's risk of a heart attack, but only $2000 per year for treatment of the same person's depression, to reduce the risk of suicide. The narcotic addict is allowed $2000 for treatment of heroin addiction, compared with hundreds of thousands of dollars for a secondary HIV infection. Our insurers face no uprising when they decide that an insured businessman deserves a new anterior cruciate ligament to allow a bit more knee stability, but an unfortunate computer operator in whom schizophrenia develops merits less than one tenth as much to prevent delusions and hallucinations.
The relatively low payments received by psychiatrists can be blamed to some extent on psychiatrists themselves. They accept their own devaluation when they sign for lower salaries or when they accept limitations on their ability to practice psychotherapy. They allow administrators and others without medical training to dictate treatment plans. And they follow the Pied Piper of pill pushing, happy to become simple prescribers, even as state legislatures grant similar privileges to those with minimal medical qualifications.
I am reminded of the late 1980s, when anesthesia was increasingly perceived as a technical trade and was challenged by the expanding statutory roles of nurse anesthetists. Rather than narrowing anesthesiology, the answer to devaluation was found by moving into critical care and pain medicine and asserting the role of anesthesiologists as physicians. Similarly, cardiologists did a service for themselves and their patients when they laid claim to angioplasty and called themselves “interventional.” The new technology brought public respect and money, which then yielded an explosion of new treatments. Likewise, radiologists decided that they could stick needles into kidneys as accurately as any surgeon, and soon radiologists were awash in black ink and learning to stick needles pretty much anywhere.
I don't know what the parallel path for psychiatrists will be, but it is vital that as insights develop into brain function, psychiatrists lay claim to them, grasp them, and never let them go. There is nothing like a brain procedure to grab society's interest and respect. In fact, I posit that the simple adoption of the term “Interventional Psychiatry” would increase the funding of psychiatrists and psychiatric research by 20%.
