Thursday, July 19, 2012

Those Evil Med Checks

Join me for a brief Clink rant over at Clinical Psychiatry News as I provide a counterpoint argument to people who think that med check practices are destroying psychiatry.

I'd like people to acknowledge that all medication management practices are not the same and that it is possible to provide good care while working in a "split treatment" or team model. With health care reform on the horizon, more practices---psychiatric and otherwise---are going to have to move to the "medical home" model and this is likely to require closer involvement with non-psychiatrist therapists. Medication management is here to stay, the team approach works, and more psychiatrists are likely to be involved in it. Psychiatry needs to adapt and it helps no one to paint all med management with the same negative brush.

Thanks for listening, I feel better.


Dinah said...

Clink wants to pick a fight with me because I said med checks are giving our field a bad name.

I stand by that. It doesn't mean I think she does bad psychiatry, and I work in a clinic where I see people for brief and infrequent appointments for 'med management'.

What's different is that in both these settings, the patient has therapy with someone who is available and is part of the team. In my clinic, the therapist is present at the medication visits, I can give instructions regarding things that should be attended to, if the patient is having problems, I can bring them in sooner, and if I need to scrunch in patients, I know who is likely not to show up and who is not much of a talker. There is at least a little flexibility.

In private practice, patients are scheduled for brief appointments and in a busy high-volume practice, there may be no coordination with outside therapists, no shared chart, and no option for "I need extra time, doc, I'm having a problem." People leave feeling unheard and disdainful of psychiatrists who they feel prescribe without knowing them.

I believe such high volume inflexible practices are not the norm, at least not where we live, but they are what people are associating with psychiatry and it's not helping our image.

Clink and I have very different views on what type of problems justify psychotherapy. We trained in a program that emphasized meds over psychotherapy, but there was no thoughts that patients should be seen quickly, not listened to, and not have their problems considered in the context of their lives. Evaluations were at least 90 minutes, many longer. Follow-ups depended on the doc or the clinic or the situation, but most of the people I know, even those who don't do formal psychotherapy, see patients for 30-50 minutes.

And no one I know would say that the taxpayer owes prisoners psychotherapy with a psychiatrist, and certainly we might understand that the correctional system is underfunded and under pressure to see many patients with few providers.

Maybe the issue isn't that of the med check doc---this does seem to be what some people want, but one of getting patients and docs to find one another in a way that fits better, so that those who just want a script land with the med check docs and those who want to talk land with the psychotherapy docs.

George Dawson, MD, DFAPA said...

Are you a spokesman for managed care? It is very disappointing to find that federal agencies like SAMHSA are pushing that model and practices like capitation that have been destroying psychiatry for decades now.

The question is not whether Med Checks can be tolerated. Med checks are just a symptom of government backed managed care. The question is how you plan to stay in business when all treatment is capitated and the medical home decides to give you even less money than you get for a Med Check. That is the real place this is headed. The only temporary bright spot will be the elimination of 90862 - but then the government and managed care will simply reimburse E & M codes just like the old 90862.

Jane said...

Clink made a good point that it is not just psychiatrists who are pushed by time and money constraints to give suboptimal care. Look at the mess that is primary care these days :/ Not every patient mill is run by pdocs.

In CA, at least the part where I live, med management and a high volume practice is the norm. The pdoc is usually terrible at returning phone calls, an appointment cannot be made for a month out, and they don't work with your therapist. Think Dr. Levin from the NYT article of yore. You get 15-20 minutes max, and they will not go over that for anything. Intake is 30 minutes in many cases.

The prison system actually sounds better than what a lot of other patients get. A lot of people cannot afford psychotherapy from a psychologist, and if they can afford one they don't have pdocs that actually keep in touch with the psychologist. It sounds like Clink actually works and communicates with the psychologists, can see prisoners right away when they are having
med issues (instead of saying come back to see me in a month. If there is a problem, please go to the ER because I have no openings before then), and she doesn't feel she needs to see more patients that she can manage effectively in order to stay afloat.

Weirdly, med management is actually better in prison that it tends to be outside of it.

ClinkShrink said...

Dinah, you pretty much made my point. The issue isn't whether or not people should have med check practices, in private practice or elsewhere. Your point seems to be that poorly run med management practices give our profession a bad name.

A poorly run med management practice would be one where the doctor doesn't collect enough information to make a reasonable diagnosis or treatment plan, where care is not coordinated with other providers, and where there isn't enough flexibility to adapt when the patient's needs change.

Yup, I agree with all that.

And I think a poorly run med management practice gives psychiatry a bad name just like poorly done private psychotherapy gives our practice a bad name (think: Satanic ritual abuse cults).

But as you said, these situations are the exception rather than the rule. And there are ways to address sloppy practices that hurt people, through medical licensure boards.

But now I babble. I'm glad we agree.

ClinkShrink said...

Dr. Dawson: No, I'm not a spokesperson for managed care although I suppose you could say that a correctional practice is the ultimate managed care!

For the sake of my column I'm separating the issues of the delivery model versus payment for treatment. I agree that providers should be paid a living wage just like anybody else.

I get concerned though when it seems like psychiatrists are more concerned about their own reimbursement than with thousands of people out there who aren't able to get care at all. I don't here nearly enough discussion about that.

I'm pleased to say I don't know what a "90862" is. I don't have to know about that, I just get to treat my patients.

Sarebear said...

I don't think med check style, sort of high-ish volume psychiatric practices are a negative thing in and of themselves when done well, with consideration for the patient, preferably with at least 20 mins per patient/3 per hour (unless a patient needs a few more minutes).

What I do think is negative for both the patients and psychiatry in general, is that many patients (practically all, if they use insurance) are limited to accessing psychiatric care through this med check model only, for outpatient, non-crisis, routine care.

It's the fact that the majority people don't get to choose what kind of psychiatric care they feel is best, or, if the ins. co. wants a doctor's input, at least the kind of care the psychiatrist thinks is best. There is little to no choice anymore, for the insured who can't pay extra OOP for a shrink who can be their "one stop shop".

Do I think split treatment can work, even be beneficial or sometimes preferred to meds/therapy from a psychiatrist only? Yes. It depends on a variety factors, but the connection that forms between patient and therapist is a big one.

In a region like mine where, at least as an insured patient, I seem to have a really hard time finding psychiatrists who aren't so full practice that they can accept a new patient for med checks, I'm guessing, for the insured, even if their co. would pay for psychiatrist therapy, that there'd be too much demand for med checks that most psychiatrists wouldn't have time in their schedules for that.

That's just a guess; if therapy to the insured by a psychiatrist was more of an option, there's probably a certain number of shrinks who'd choose to do it, even with the high demand for patients to be seen for the minimum outpatient routine psychiatric care.

So, the bad thing is reducing the options of care patients can get, reducing the options of care psychiatrists can give, forcing both parties into a model of care that may feel constricting, restrictive, and not necessarily always meet the patients needs.

So I agree w/some of Clink, and some of Dinah, with some of my own thrown in there, and we all (well us three) seem to agree on some points.)

ClinkShrink said...

SareBear: You said it best. Thank you.

Anonymous said...

I work as a med check psychiatrist in a clinic. I see 3 patients an hour and all patients have access to therapy in the same building as me, a model that has been in existence since the 80's at least. I give good care and I know a lot of others who do too. My patients regularly thank me for what I do. And I coordinate with therapists on site, and many agencies in the community. Are we perfect? Nope. But we are dedicated to what we do. And we are not getting rich.

There are some private psychiatrists who would not agree to treat a lot of the difficult patients that I do, either because of insurance coverage, or inability to pay, or just because they are too complicated.

The economic reality is that clinics can't stay open using a 1960's model. They are not milking the patients for more and more profit. They are surviving.

Amy said...

I've had med management psychiatrists who took insurance who were fabulous and very much on top of things. If I wasn't well they fit me in faster then then the next appointment; if I was doing fine (on all acounts), they left me alone at 3 month check ins; if I was somewhere in the middle, we compromised on phone and more frequent in person sessions. Sessions were 20-30 minutes unless there was more going on and then they were magically longer. The woman was brilliant and saved my life singlehandedly when she went for the older anti depressants without fearing their elevated danger risk. At some point in my treatment with her I saw a therapist who was not in contact with the psychiatrist; most of it, I didn't.

I have also seen some of the ultimate "best of the best" elite NYC psychiatrists-who-also-prescribe therapy. Under one the twice weekly and tens of thousands of dollars worth of care of one psychiatrist, I was loaded with heavy duty psychotropic meds, given strange diagnoses, hospitalized multiple times, and ultimately out on disability. This woman is guilty of ethical and practical infractions and is barely competent to practice. Sad that it took three years before I could get away from her.

My personal preference is a psychiatrist who also provides therapy, as I am not a big talker and I like being able to have one person responsible for meds and therapy. However, I have absolutely been in situations where med checks work. To be honest, I think it comes down to the quality of the doctor doing them.

Dinah said...

Amy-- the flexibility you describe is counter to the type of treatment I mean when I say 'med checks are harming our field.' You clearly feel your doctor knows you and is responsive to your needs, not 'running a racket.'

George Dawson, MD, DFAPA said...

"I get concerned though when it seems like psychiatrists are more concerned about their own reimbursement than with thousands of people out there who aren't able to get care at all. I don't here nearly enough discussion about that."

That is an interesting viewpoint given that anyone who depends on insurance companies where there is any degree of managed care reimbursement can end up so little they cannot keep the doors open. Managed care capitated rates will all be a feature of the new health care landscape and I predict that it will result in a substantial reduction in reimbursement. My background by the way in public hospitals and clinics that depend on MA and Medicare and managed care is the only system that will pay you less.

The issue isn't psychiatrists more concerned about their reimbursement - it is the government and the insurance industry wanting you to work for free (numerous examples).

ClinkShrink said...

I doubt that payment to doctors is the key make-or-break factor to keeping a clinic or hospital open. It may affect where a doctor choses to work, or the decision to go into a particular specialty, but there are a lot of other costs to running a health care system. I don't doubt that under a single-payer system doctors will get paid less than as a private practitioner, but I'm not quite ready to accept the worst-case scenario.