Psychiatry’s Underground Economy

Psychiatric TimesVol 31 No 9
Volume 31
Issue 9

It seems to this psychiatrist that a significant cohort of his colleagues conduct their practices in what might best be described as an “underground economy”: a system of services and charges disconnected from the conventional constructs by which these activities are presumably measured.

I read with interest two articles in the July issue of Psychiatric Times: Dr Richard Friedman’s “Issues in Psychodynamic Psychiatry” and Dr Thomas Insel’s “The Paradox of Parity.” Both of these articles were thoughtful and timely, and helped me clarify a point of view that I have thought about for some time. It seems that a significant cohort of psychiatrists conduct their practices in what might best be described as an “underground economy”: a system of services and charges disconnected from the conventional constructs by which these activities are presumably measured.

Despite all the work that has gone into the descriptive-based DSMs, CPT codes, and RVUs (relative value units), all of which presumably categorize and put values on various psychiatric interventions, a good number of psychiatrists simply charge for their time (regardless of how they are spending it clinically) and at rates that reflect the valuation that they place on it-a value generally determined by years of training, years in practice, and any additional post-residency certification (eg, fellowships, psychoanalytic training).

The two articles covered a lot of territory; however, both reference the challenges and pitfalls that occur when one attempts to translate the practice of psychiatry-the most personal, individualized, and subjective of medical disciplines-into data points that can be used in the service of evidence-based medicine.

Friedman questions our current preoccupation with evidence-based criteria, is wary of a growing trend that restricts clinical psychiatry to the brain at the expense of the mind, and is critical of a diagnostic system that cannot account for unconscious forces. He fears restricting the scope of psychiatric practice and argues that there are some psychotherapy patients that only a psychiatrist should treat.

Insel, a consummate scientist and researcher, seems more invested in evidence-based medicine and the potential of integrating data derived from research into clinical practice. However, he acknowledges that “parity” in mental health may have unintended negative consequences. He is particularly concerned that this same research might be used as an excuse for limiting some psychiatric treatment. He also notes the startling (but seldom acknowledged) fact that only 55% of psychiatrists accept noncapitated insurance.

I, too, have concerns about the rise of evidence-based medicine. Not only in how it might affect insurance compensation, but also in how it might further contribute to a disconnect between psychiatry as envisioned by DSM, CPTs, and RVUs, and how the art of clinical psychiatry is actually practiced by many clinicians.

The year 2013 was big for psychiatry: there was the expansion of CPT codes and the launching of DSM-5. The former was particularly significant in that it eliminated the overly simplistic medication management code and encouraged the use of Medical Evaluation and Management (E & M) codes, particularly as add-ons for psychotherapy. It also introduced separate codes, 90839 and 90840, for providing psychotherapy for high-risk crises patients.

These developments were praised by the American Psychiatric Association and have resulted in better reimbursement rates. However, it strikes me how little discussion there has been in the psychiatric press or at the various symposiums, conferences, and grand rounds that I have attended about how clinicians are actually choosing to apply these CPT changes. Do the E & M add-ons refer specifically to pharmacology and/or comorbid medical problems? Or, can a psychiatrist legitimately argue that years of medical training and practice allow many aspects of the doctor-patient relationship to be seen through the lens of medical evaluation and management? The lack of discussion about these matters suggests to me a disconnect between the academic and medicoeconomic forces behind instituting these CPT changes and actual clinical practice.

I cannot recall how many times I have been warned over the course of my more than 30-year career that psychiatrists must be prepared for a “new model,” where we would inevitably be part of a “multispecialty team.” Our work would be limited to what only we can do: psychopharmacology, diagnostics, crises, and inpatient work. More recently, the buzzword has been that our work will be, of course, “evidence-based” (as determined by “research”).

I understand that many psychiatrists spend much of their time working collaboratively with nonmedical therapists (which is great) and a good number of us restrict ourselves to pharmacology only (which I think is unfortunate). I also realize that few of us are completely immune to these economic forces. Yet, I also see plenty of evidence that many of us, young and old, continue to seek solo, office-based, fee-for-service, private practice. And those of us who participate in this world of private practice, RVUs, and evidenced-based models often seem far removed from the actual time and effort we spend with our patients.

I doubt that most psychiatrists who provide psychotherapy, particularly those attuned to transference-based models, charge their patient more or less for a session depending on how suicidal or impulsive that patient is on a given day (despite the existence of the 90839/90840 codes). I also wonder how most of us determine our E & M add-ons. Do most psychiatrists really quantify the E & M effort for each individual session, or is it more of an issue of taking into consideration how assessment of medication, medical illness, etc, average over the course of treatment?

Who can argue with the importance of research? It is essential for the advancement of our field and the health of our patients. Yet, for evidence-based medicine to be meaningful, it must inform and be informed by clinical practice and be mindful of the unintended consequences that encourage the real economy of psychiatric services to go “underground.” Despite all the slicing and dicing of psychiatry into a multitude of RVUs, diagnostic categories, and CPT codes, it remains to be seen how accurately these constructs reflect how clinical services are provided and compensated for by much of rank-and-file psychiatry.


Dr Levinson is in private practice in Chicago, and he is Assistant Professor of Clinical Psychiatry and Behavioral Sciences at the Feinberg School of Medicine, Northwestern University, in Chicago. He reports no conflicts of interest concerning the subject matter of this article.

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