Monday, January 13, 2014

Why Psychiatrists Don't Participate with Insurance Networks

In 2007, I wrote a post called Why Shrinks Don't Take Insurance.  The post is a bit dated, the CPT codes have changed since then, and the reasons to not take insurance have increased.  Many other doctors don't take insurance now, though psychiatry remains the number one specialty where doctors don't participate in health insurance plans.  This is an updated version of that same post.

Many psychiatrists in private practice don't participate with insurance insurance panels. They require the to patient pay  and then the patient has the option to submit a claim to his health insurance company as an "out-of-network" service,  and reimbursement is made directly to the patient. This may mean that the patient has a higher co-pay and deductible, and the hassle of doing the paperwork.  It also means that if the insurance company does not send reimbursement, that the cost is incurred by the patient, the doctor has still gotten paid.  If a patient sees a psychiatrist in his network, he pays the deductive and co-pay and the hassle of getting the rest of the money falls on the doctor.  Now the overall expense of an out-of-network psychiatrist may or may not be lower -- some plans have excellent out-of-network coverage -- but any way you look at it, the hassle and financial risk are less if a patient sees doctors who participate with their insurance.

Because many psychiatrists do not participate, it means that access to psychiatric care may be limited to those who have the money to pay up front,  and the wherewithal to stick their statements into an envelope and send them to the insurance company-- after they've called a separate managed care company, gotten
pre-authorization, and had Dr. Shrink submit a treatment plan. They must assume the financial risk that the insurance company might find some reason not to reimburse.  Over on PsychPractice, our colleague has a post up about an insurance company that lost the claim, then wouldn't pay it because it was then submitted late, and then wanted the psychiatrist to provide references as to why out-of-network service is necessary.  It's about the number of hoops, how high one must jump, and whose going to do the jumping.

 By not accepting assignment, the doctor has greater control about what he is  paid, but the patient supply becomes limited in a way that restricts access to care.   Patients who want the financial and logistical benefit of remaining in their network are often surprised to find that it's difficult to find an in-network psychiatrist (even though the insurance company often has a large list of dead providers) or that those psychiatrists aren't taking new patients, or that they see patients for brief med checks but not for psychotherapy, or that it's hard to find a psychiatrist who feels warm and fuzzy enough. From the patient's point of view, it's not fair. There's a reason for this: it's not fair.

So why don't all shrinks accept assignment, why aren't they lining up to be members of insurance networks who would funnel lots of patients their way? Let me tell the story from the psychiatrist's point of view.

  •  If a psychiatrist doesn't accept assignment, s/he sets his own fee-- generally what the market will bear. This one is easy, everyone understands wanting more money, and the insurance company fees are often less that what a psychiatrist can charge if he does not participate. 
For some psychiatrists, that's the bottom line. For many, however, it's about much more: the paperwork and the freedom to practice psychiatry as he wants.

  • If the psychiatrist accepts assignment, he agrees to practice according to the terms of the insurance company. He sees the patient and collects the copay. Maybe it's a flat $30 co-pay, after a certain deductible. Maybe it's 80% for the first 5 visits and 70% for the next 5 visits and 60% for all the visits after that oh but the patient is only covered for 25 visits a year and the psychiatrist has agreed not to balance-bill as part of the deal. I don't know what happens if the patient needs a 26th appointment, I believe the doc eats the fee or simply doesn't offer the extra sessions. At any rate, the doctor now needs to figure out how much the patient has to pay and it's his responsibility to collect this. Oh, but it's not 80%/70%/60% of HIS fee that the insurance company will pay, it's 80% of what the insurance company has decided is Usual & Customary Rate (UCR) which is set by the insurer. And while it might be a piece of cake to calculate if the the UCR was say $100/appointment and the patient paid $20 and the insurance company paid $80, but it's a pain in the neck if the UCR is $97.84/ session and you have to keep count of the sessions and figure out the percentages. Should I mention that different insurance policies by the same company can have different payment rates so someone has to call for each patient, verify the insurance, find out the terms, co-pays, deductibles, and this involves sitting on hold and dealing with assorted prompting menus. Did I mention that some patients have two insurance policies?  When I accepted Blue Cross in the early 1990's, they would send me checks for $12.44 for 50 minute sessions.  I never did figure that one out, nor could my three billing secretaries explain it. 
  • While many psychiatrists in private practice are able to manage their practices without secretarial support, a psychiatrist who practices in-network usually needs a secretary, an overhead expense his I-don't-accept-assignment friends may or may not want or need. And he now has to have an office big enough to accommodate secretarial space. I'll also tell you that while the secretary is paid an hourly fee, his ability to get paid is only as good as her motivation to follow through on dealing with the insurance companies, refiling denied claims, clarifying primary versus secondary insurance and getting the amount of the co-pays correct.
  •  And if the insurance company finds a reason not to pay, the doc is stuck--he can't bill the patient, he's just out the time/money. For a psychiatrist who does psychotherapy and sees 8-11 patients/day at an insurance company discounted fee, doing work that does not get reimbursed is a problem. A doctor may decide he can afford to take on some patients at reduced fees, but it's infuriating to be subsidizing an insurance company because the forms were filed with something coded wrong, or because the insurance company lost them. 
  • Increasingly, insurers have requirements for how the doctor practices.  Medicare has it's 1.5% fee cuts for doctors who don't e-prescribe.  They have incentives to get doctors to figure out "meaningful use."  There are fee cuts if PQRS codes are not done.  They still take paper claims, but will likely soon require electronic submissions.  Every segment of these mandates requires a large investment of time and often money.  Really?  Click on the "meaningful use" link I  provided and try to read the entire page.  Here it's hard to figure out where the hoops are, much less how to jump through them.

So  why does any psychiatrist accept insurance?  Some doctors don't get enough referrals without participating, some are simply afraid they won't so they don't drop out of networks, others practice in areas where people simply can't afford to take insurance.  In some areas of the country, this is just not a mind set: everyone takes insurance, and psychiatrists just do med management.

  • Insurance companies pay reasonably for short appointments with a psychiatrist.  A psychiatrist who sees two patients in an hour makes more than a psychiatrist who sees one patient in an hour, and often the insurance companies-- perhaps eager to encourage their policy holders to seek psychotherapy with a cheaper clinician-- will pay a reasonable amount for a shorter session-- perhaps they make this worth doing. A psychiatrist who can see four or five patients in an hour and who has a secretary and has a system in place can do well financially by billing insurance companies, but it does require volume.  A psychiatrist who sees patients for hour-long sessions will be disadvantaged and that's why in-network psychiatrists don't usually provide psychotherapy.  

What you don't hear when you read about how psychiatrists don't take insurance is that we still like what we do.  I still have a job where I spend each hour listening to patients without interruption, I then put a note in a real paper file in a metal filing cabinet.  I just read that the average primary care doctor spends 2/3 of their time on clerical work.  I'm happy to say that I spend the vast majority of my time in e-free sessions with my patients and I'm hanging on to that for as long as I can.  But it's not just about the money, it's about three things: the money, avoidance of mountainous paperwork hassles, and the the freedom to practice psychiatry in a rewarding way.


Joel Hassman, MD said...

Amen. Check out John Grohol's column on this from yesterday at

L said...

Ah, but there should be a control for how high a psychiatrist providing therapy can charge. I live in the most expensive city in the US but $500 a session is insane. (I am not exaggerating; I pay a deep discount according to a sliding scale.) There is no reason for the market to "bear that."If more psychiatrists charged realistic fees, insurance would be less of an issue.

catlover said...

I don't mean this post sarcastically at all - really, this was a revelation to me. I get it now why all the people with serious mental illness are stuck with 15 minute meds checks once every 3 months. Those who are the "worried well" or have more minor problems get all the time in the world with a psychiatrist because they can still hold down a great job and can afford to pay for it and/or are well enough to do the paperwork and phone calls to submit their own insurance forms. Ah, but get too sick, not able to work anymore, or only at a low paid job, it's all over, because you will get poor peoples' care with the 15 min med checks and antipsychotics up the yin yang. You'll be too depressed to get pre-authorizations and send in for reimbursement.

I never HEARD of 25 appointments a year with a psychiatrist! Maybe there is a regional thing going on, too. In my state, I am pretty sure there aren't that many psychiatrists because 2 psychiatrists who blog from my state say that and their complaints about care often overlap mine.

I get it now why sometimes I read psychiatry blogs and it's like they are coming from an alien planet. They are! I get poor peoples' care. I didn't realize that when I go to the regular medical clinic and the visiting psychiatrist is there, that's the poor peoples' care. A lot of the people commenting on blogs don't provide poor peoples' care or they are patients and they don't receive poor peoples' care. I must have missed some blog posts that I didn't ever get this, or that discussion was back in the days I was constantly doped on antipsychotics.

R said...

I'm curious why you state that if insurance denies payment you can't bill the patient. I know I've gotten bills from doctors (albeit not psychiatrists) when my insurance has decided treatment after I've received it. Why would psychiatrist be different in this manner?

Joel Hassman, MD said...

Just curious, why is it the insurance industry has set a tone for mental health to be discriminated against still to this day, and now so many colleagues who are non psychiatrists, and now even most psychiatric patients will follow suit without hesitation?

Why is it people are begrudgingly willing to pay what amounts to top dollar to access responsible and appropriate cardiac, oncology, GI services, or even elective surgery for what amounts to vanity procedures like augmentations and non essential corrective procedures, but, patients will literally bitch and moan about a f----g $20 copay for an honest 20 min med check that involved some dialogue beyond the usual standards of medication monitoring. Do you pull these stunts in your PCP or surgeon's offices too?!

I'll relate the most common dynamic to why patients will nickel and dime providers as much as insurers do-- they try to use our consistent and well meaning compassion and empathy we learn and perfect in the person-person interaction that goes further than the doctor-patient interaction against us when we have the right to collect the fees we tell you, the patients, up front what the care costs.

I have seen first hand people say without hesitation they would commit to paying an exorbitant fee for a medical procedure if it saved or prolonged a life, and yet don't get it that restoring mental health has the same endpont. It's just not documentable on a piece of paper, on an xray film, a lab result, or some other objective reading.

No, mental health is a subjective experience, but, it has tons of objective outcomes you just can't measure in the office at moment "X" that justifies this quick fix and immediate gratification expectation that has logarithmically grown for health care outcomes the past 20 plus years. And frankly, while most who write here won't consciously accept it, if it wasn't for the psychiatrists who have fought continuously to now the corrupt system so many blogs write about, you would be in even more trouble than you think you are now.

But, let's face it, when it comes to mental health, people want a free ride by in large. I see it daily at every CMHC I have worked in the past 10 years now, and it is obscene for most examples. So, posts like this will either be railed at for being absurd and audacious to claim we should make a living, or will just be dismissed and denied as having any legitimate concern.

We don't do overt invasive procedures and literally snatch the risk of death from someone lying on a gurney or operating bed, but boy, have I heard more than a few patients say in almost so many words, "if it wasn't for you/other mental health providers/other supports who weren't there for me until I accepted and pursued care for my mental health problems, I would be dead and gone."

(to be continued due to 4096 character limit)

Dinah said...

Thank you, Joel, I posted a link over there.

L: the people who can afford to pay $500/session are subsidizing your deep discount. If your doctor was not allowed to charge that as his base fee, he would not be offering sliding scale discounts.

Catlover: You are absolutely right, it is a 2 tiered system where the poor peoples' care is totally different. On the other side of it, clinics usually offer treatment with social workers for the therapy, and they help coordinate getting services and benefits, sometimes there are case managers and outreach services and help with things psychiatrists are not good at. And in the clinics I've worked in, I found that many of the patients had no interest in regular or frequent psychotherapy (poverty does that) and few had computers and were spending much time on psychiatry blogs. But you're absolutely right.

Joel Hassman, MD said...

(and the ending)

Yeah, you won't see those dramatizations on the next medical care drama this week, but, we do save lives, and we do it because we care and we sacrifice. We just aren't priests or some other altruistic group who do it to just go back to a hut or cave until the next sould comes a callin'!

This dialogue is so old for me, I don't ask someone to pay me $500 for a therapy hour, and I don't know who or where that legitimately could be asked. George Carlin was right when he said especially with the Boomer generation when they just say with intensity and demandingness, "gimme that, it's mine!" I think people as a whole honestly believe that mental health care should be on the same level as what religion offers. It is free and a charity process, and people can donate to it if so desired.

And in my opinion, as a late Boomer, that attitude has metastasized down to further generations, just called a different name or behavior.

Yeah, this rant is over, and I hope some of you give perhaps a second or two to comprehend what happens when the altruistic and well meaning doctors finally say, "F--k it, I'm done doing all the fishing!"

You'll have to eat tomorrow!!!

Anonymous said...

I see a psychiatrist and it's a meds only practice. I pay out of pocket, but it's reasonable. I don't seek reimbursement from insurance because I don't have the organization it requires or patience or sanity to deal with it, and since it's meds only and not that long of an appointment it's not that expensive.

Currently,I see him every one to two months. When I was not doing well, I saw him much more often.

It's true that the patients who get lost in the shuffle are those who are most ill. When I was not well and not working, I wouldn't have been able to manage all that was required to get to the community based mental health services. Bring this form to prove lack of income, do this, do that. I wouldn't have done any of it. So, if that were to ever happen again, I know my parents would help me with funds to continue with this psychiatrist because all the hoops you have to go through with community based care are difficult, if not impossible, for people when they are really sick. You have to be very organized and together, and if you are that organized and together then you probably don't need the services all that much. At least, that's how it is in my city. Probably other cities are a lot better at community based care.


catlover said...

Dinah, I thought I posted this, but maybe not. The social workers and other mental health workers that come to the home don't do anything! All they do is fill out paperwork to keep themselves coming. I'm not kidding. It is awesomely ludicrous.

I spent a lot of time socializing with other people with problems, and they don't want therapy because they were taught, TAUGHT that they need to take pills to control "their illness" and everything wrong is because of their illness, even though most of them had trauma histories! And right, they don't know any different because they aren't educated enough to use the computer and read blogs - those who do read up on mental health read websites like NAMI who push the everything is your illness idea.

I have a strong idea now that it's these social worker type people pushing some ideas, because their purpose in society apparently is to keep the madmen from running amok and shooting people, not to help people recover. Or maybe it's the hospital staff that do this. Illness management classes. I don't know. Somebody taught them.

The problem with paying to see the psychiatrist, or even more so, the therapist, is a patient goes so often. My father saw his cardiologist only once a year, my husband sees his orthopedic surgeon and retina doc once a year, and so on. Otherwise, the family doc does everything, and I bet people complain to the family doc about the copay too. At a community clinic, maybe 20 bucks is really too much, on top of the bus fare and prescription costs. LOL, but then they go get a pop out of the machine, I know. The people I know who are like that, they really aren't too bright and have nearly zero math skills and I think that's part of it. But you know, that's poor peoples' complaining. Better off people get fancy home loans and new car loans then complain about the cost of a new dental crown. I hear it from that end, too.

Anonymous said...

Catlover, I never had much luck with social worker either. When I was in the hospital, I was required to meet with a social worker who took my information then informed me he wasn't familiar with the services in my city (I lived 2 hours away), then he billed for telling me he couldn't help me with anything. Definitely needs to be more oversight.


Je Suis said...

Some interesting comments here that I would like to respond to:

1) "No, mental health is a subjective experience" - this is true, but then, sometimes the subjective experience is a negative or, at best, useless one. However, the 'patient' can still be forced (I'm thinking involuntary commitment here) into accepting that useless or negative experience based solely on the whim, or instinct, or whatever you want to call it, of the mental health provider, negative experience or not. Oh, and then be charged an exorbitant fee for the 'help'.

2) "We just aren't priests or some other altruistic group who do it" - no, you are definitely not that. A priest or other altruistic group cannot force someone into accepting their "altruism", regardless of the circumstance, You, however, can. For pay.

3) "You are absolutely right, it is a 2 tiered system where the poor peoples' care is totally different." Alright, now that we acknowledge that truth, can we then agree to act on it realistically? What I mean is, if there is indeed a 2 tier approach to access to care, then there must also be a two tiered approach to the actual care. For example: an
attempted suicide. if the suicidal individual has the means, then give them the option of all the care they can afford, while a suicidal individual without the ability to afford such care should just be released to go about their business, even if it is completing the suicide attempt. That seems fair in light of this two tiered system of care. Stop forcing help on those who neither want it nor can afford it. This would accomplish two goals: the Psychiatrists would not have to fret over getting paid, access to care would be available for those who can afford it, and long term mental health issues would be alleviated somewhat, as those people would begin to die out. Would this solve the problems with problems associated with mental health care sufficiently?

In the end, the mental health practitioners want it understood that their profession is a business, with all the associated costs of a business. That's fair, but then, I have a problem with being forced (in some instances) into transactions with that business. After all, "cardiac, oncology, GI services, or even elective surgery" are also businesses, but I can opt to not
engage in that business with them, even to my detriment (I have already done so, by refusing a colonoscopy). Not so with psychiatry. Psychiatrists can force the issue - just be 'dangerous' - an opinion, by the way - and you have no choice. You WILL 'do business' with the profession. And pay for it dearly.


L said...

Right, but if he charged a reasonable fee in the first place, I wouldn't need a discount.

Borderline said...

500 a session? Dang. I have wondered what the world would be like if healthcare were affordable. People didn't think twice about accessing healthcare. It was as affordable as buying necessities at Wal Mart.

I remember a comment from a doc on another site where he said that he found a lot of his Medicare patients had trouble paying. And that doc accepted Medicare. So he lowered his rates in order to get them lower copays. He said he got so much business that it made up for the fact that he lowered his rates.

Anonymous said...

NYC's answer to the $500/session was AOT. It's not that people who need help in those areas don't want treatment, they cannot afford it. At that rate treatment is limited to the wealthy neurotic who visits his psychiatrist in a pricey brownstone. Not everyone has the funds to do that. I know I wouldn't.

The answer to the lack of access is not increased use of force. The answer to the lack of access is increased access. We have it backwards.


Anonymous said...

Joel Hassman-I can’t understand why you are attacking patients this way.
You state” Why is it that people begrudgingly are willing to access reasonable and appropriate pay top dollar to access cardiology , oncology and G.I. services….”.
To whom are you referring exactly? I am able to find specialists in every field who accept Medicare, other than psychiatry. I have seen the Chiefs of Hand Surgery at two major Teaching Hospitals in New York who both accept Medicare,as well as numerous other prominent doctors in every specialty other than psychiatry.I switched to Medicare only recently from private insurance.I had exactly one internist who opted out of private insurance and then out of Medicare.
So who exactly is paying all these other specialist out of pocket,and why, as patients can easily find physicians in every specialty other than psychiatry who accept private insurance or Medicare? Perhaps this is true of Manhattan.I have found doctors on the North and South Shores of Long Island in some of the wealthiest neighborhoods, who accept insurance, as long as they are non-psychiatrists.
Also, you seem to distinguish between “Willing” and “Able”.
I don’t know who is nickel and diming you over $20 co-pays,
I would be THRILLED if I could find a psychiatrist I could see for a $20 co-pay ,or a $50 co-pay.
I am being quoted $550 for a consultation and $350 or $250 for a 20 minute medication management follow-up.
I can not afford to pay this.This is not a matter of “unwilling”. This is a matter of “Unable.”
I agree that the reimbursement rates under Medicare (I am less familiar currently with private insurance reimbursement rates) are unfairly low to psychiatrists,as compared to other physicians.
But please, do not shift the blame from those who have decided to grossly underpay psychiatrists
onto the patients. Unless that makes you feel better about opting out on your patients.
I do wonder:Do psychiatrists ever wonder what happens to their patients of many years,after the psychiatrist announces that he or she is opting out? Do you consider that a patient who is suffering from severe depression may commit suicide as a consequence? After you opt out, do you think of your former patients at all?

Joel Hassman, MD said...

Let's look at this anonymous rebuttal point by point:

1. Yeah, people really try to nickel and dime other specialties? I can't wait to read the copious vignettes from readers who told the cardiologist "I will only pay $150 for that stent placement", or, perhaps to that neurosurgeon, "if the meningioma is only 2cm in diameter, will you give me a discount?"
2. You want to visit the Doctor Hypocrite page, try to get most specialists who take Medicare admit that if they could get out and not have to endure some headaches with the feds, they wouldn't jump ship faster than you could say "Man overboard". What is this irrational fear that the government has you, the doctor, bound and gagged because you once decided, or had to be in Medicare for a place you worked at that HAD to accept it, like being a hospital employee? And remember that little story about having the man treat you who resented being controlled by outside forces, do you want someone who has to do what is told that is wrong and contradicts the standards of care, or perhaps the one who doesn't care about being compromised??
3. ANd what is this extension of treatment in New York City have to do with the other 98% of America, does LA have the same stories too? No, I know the NY ego trip perspective, and New Yorkers aren't better or entitled to pity or remorse because you chose to live in a city of what now, 12 million?!
4. To my above point in #3, explain to all of us how people could bitch and moan about being charged $150 for an hour eval and $50 for a full 20 min med check in Annapolis MD in 2009, which to those who know that town, that is a damn cheap charge. Oh, and how some could somehow extrapolate in the complaint of what I charged how other doctors were charging $275 for the same eval and $125 for a med check. Yeah, it really does fit my earlier rant that people have become so damn cheap and entitled, they think they can talk you down from an already more than fair rate. Like, what Medicare does to doctors now, EH?!

(part 2 comes up next)

Joel Hassman, MD said...

Part 2 here:

5. Opting out of my patients? For the risk that Dinah will either strike this comment from the thread or just banish me hereon, who the hell are you to judge me, someone who has believed that everyone should access care I provide, whether it would be the President or a homeless man sitting in the same waiting room? A doctor who has done private practice AND CMHC together for much of my career until recently. Who still does CMHC for now, but won't lie, that will change by the end of 2014, but not because of reimbursement, but for the dumbing down and quick fix demands of all who are in that system now (read my blog, it seems to explain this well!). So, suck an egg, don't try to anonymously accuse me of abandonment or insincerity, without knowing some details first!
6. Lastly, for someone who has had to leave clinics and practices because I can't live on a vow of poverty, like you infer, it hurts big time to say goodbye to people you have cared for over many months and years. They know it, I know it, and then some antipsychiatry loser who wants to either stick an ice pick in my back, or better yet over at 1boringoldman a couple of months ago, pistol whip Freud as a loving extension of getting at psychiatry as a whole, thinks I can be the punching bag for pleasure.

Yeah, cause I call it as I see it, after 20 years of watching so many inappropriate influences nickel an dime and devalue what psychiatry realistically and responsibly does do when not beholden to insurers, big pharma, and ego maniacs that run the APA and most of academia.

Figure it out yet, I am pissed about the lack of concern and lack of effort in trying to get psychiatry as a whole back in place, being the leader and acting with responsibility, integrity and compassion. One day I won't be figuratively out there by the water, catching all that fish for a lot of people who have redefined pathological dependency.

Maybe read this 2 part post a couple of times before the usual reflexive retorts and holier than now denials that docs can care, and say it tough and loud!!!

Borderline said...

Joel, deep breaths. It's just a website. It isn't real.

Joel Hassman, MD said...

"it's just a website, it isn't real."

What the hell is this!?

Do any of you here understand what this post has evoked in someone like me who saw what the insurance industry did to psychiatry? I think after tonight I understand what it is like to figuratively be raped. Really! To have your personal being be violated, to have your professional training be so compromised, be so de-legitimized, to have people who have no f-----g clue what the process to mental health care is really about to come in and tell you how to do your job, what you are to think and do, that is basically what a rape is, true?

Here are the facts to what the full circle is for me now almost 20 years later:

In 1995 the APA had an election for President that was between Steven Sharfstein, and Harold Eist. The undertone of the election was basically would psychiatry accept managed care. Sharfstein had an undercurrent of "managed care is here to stay, deal with it" campaign, and don't let the apologists and defenders of this bullsh-t tell you otherwise, it was, as Harold Eist would tell you I am pretty much on the mark. Eist was against it, fully, and he won. 52-48% of the vote. 48% of psychiatrists supported Sharfstein and his sell out. So, does that give you some inkling to why I am what I write about at my blog as of 2014?

So we as psychiatrists watched managed care set the tone for this profession for the next few years, and every chip, every concession, and so many doctors just kept on agreeing with this sick mantra of " that's just the way it is, so things will never change", and sold out the profession. Think about it for a minute if you have been in care for more than 15 years now, how many psychiatrists have you met since then who have told you in almost so many words, "you have a biochemical imbalance, you need meds, and that's just the way it is"? What a piece of sh-t mentality that is, and, this will annoy if not sentence me to banishment hereafter, the APA bought it, sold it, and now has made it the mantra for the profession with DSM5. You think otherwise colleagues, well, you better hope there ain't an afterlife, because if you really think my position is completely out of line, well, good luck!

But, here is where you need to understand why I just went nuts when I first learned about Obamacare and it's agenda in late summer 2009. First, I hate politicians, as they basically hate us as a field and the people we treat, but, then I found out through the grapevine that the insurance industry, and the pharmaceutical industry, would be supporting this legislation. That was the wake up call for me to say "No F-----g way am I going to say nothing to this!"

And now here it is 4 months into this monstrosity, and what a sham, but moreso, what a lie this legislation has become. And yet, I feel like my colleagues are what the Jews were in the beginning of the Final Solution by the Nazis in Europe. "oh no, they won't do terrible or atrocious things to patients and providers, this bill will help people." My god, how many times does history have to repeat itself, maybe not profoundly repeatedly, but at least figuratively, and watch a group of people be horrendously punished and ruined, if not brutally murdered, for people to figure out the needs and sick agendas of the few will pervasively and profoundly screw the needs of the many.

(once again per character limits, part 2 follow...)

Joel Hassman, MD said...

(and part 2 and the end...)

Hey, we watched 4 people die in Benghazi for no good reason, so, why do you think the architects of health insurance run by bureaucracy really care what happens to a sizeable portion of America? They already are telling you that the 4-6 million who lost insurance at the end of 2013 because of Obamacare is "inconsequential" if not meaningless, is that number of 6 million coincidence, or, just not those who matter to those in power?

I realize now after writing this comment I am done here, and perhaps I am done trying to reason and help people realize what is going on with the intrusions, the disruptions, the lack of accountability, the flagrant "I don't give a s--t" about the public, but the partisan agendas that rule politics and the crony agendas.

So, yeah, it's a just a post. Maybe Dinah might be a bit offended by that last comment before mine, hey, your opinion is just a post, who cares!

Let me end with this, one day down the road, it may be by the end of the year, by the next Presidential election, or further, but, consider this: people like me who have cared, who have spoken out loudly and harshly, who want to do what is right and responsible, we will see at some point that a sizeable portion of society doesn't care not only about the rest of the community, but even themselves, and we will see the writing on the wall. And we aren't interested in being martyrs, in being sacrificed, in wasting more time and effort to educate and redirect, we will save ourselves and our families and the precious few who do pay attention and realize the jig is up.

History has played that one out too. you have to repeat that one to find out who survives, and who doesn't? Write me off as a crackpot, an extremist, clueless, outrageous.

If I am wrong, you'll all be happy. But, I pay attention, and I wouldn't write this missive if I was so stupid and reckless.

Good luck with that status quo!

Done!!! Have fun at my expense!!!

Dinah said...

Oh, my.

I just wanted to explain why psychiatrists don't take insurance.

It wasn't meant to be a violent issue.

Borderline said...

What I mean is that blogs aren't real in the same way as an APA meeting, exchanges in real life with pdocs, etc. For instance, I am not sure I believe in internet romances as "real." There is a big difference when hitting on someone in real life, dating in real locations, having sex (not in a chat room).

My point is, your facebook friends are not always your real friends. And this blog is not a real place where real decisions about policy are being made. I thought it was just supposed to be a fun little blog, with a yellow ducky, that talks psychiatry. I think the fact that they have a yellow ducky as their mascot speaks to just how "seriously" the blog owners take themselves. They don't think they are the official website for the next DSM. They seem to be purely social and doing this just for kicks.

blog tali rafia said...

So, yeah, it's a just a post. Maybe Dinah might be a bit offended by that last comment before mine, hey, your opinion is just a post, who cares!

Lee said...

The problem is that our current insurance model is not designed with the patient in mind. I don’t blame therapists for not wanting to work with the insurance companies, who seek to dictate treatment in an effort to reduce costs and increase profits. My therapist doesn’t accept insurance. Not only that, she won’t even talk to insurance companies. So when my insurer came knocking and asked for a prospective review to verify her services, she refused to comply and my mental health benefits were terminated (although the company is all too happy to continue to accept my premiums each month).

My therapist is willing to slide her fee, but she can’t slide it all the way down to my former co-pay. So in this model, the patient loses. The insurer saves money, the therapist gets to remain loyal to her model and principles, and the patient has to choose between paying more out-of-pocket, finding a new provider altogether or simply terminating. Either way the patient loses.

Je Suis said...

To Joel Hassman, MD

A few points to try to add some perspective:

1) "explain to all of us how people could bitch and moan about being charged $150 for an hour eval and $50 for a full 20 min med check"

O.K. - this was in 2009, right? according to the Bureau of Business economics research, the average per capita personal income in 2009 was $38,637. So, extrapolating the $150 an hour charge for a regular 80 hour working week results in a $218,400 earning for the year. Seems a bit unbalanced in that light. Especially when there is no guaranteed outcome with psychiatry - maybe you'll get better, maybe you won't, maybe it'll take years; there's just too vast a list of variables involved. But, the one thing you are adamant on, apparently, is that your professional value is so high, even with the uncertain outcomes, that you deserve to charge what amounts to niche prices. Fine. Do so, but,leave those of us who cannot afford such costs, or are unwilling to shoulder the burden of such exorbitant pricing, alone. By this I mean no involuntary commitments, no forcing your services on someone who is not interested. If they want to commit suicide, and don't want your help, at your cost, then let them. After all, it's a free market (sort of), you are able to charge what the market will bear, so the consumer should also be able to decide what goods and services are acceptable at the proffered cost, and reject those they deem unworthy.

2) "Do any of you here understand what this post has evoked in someone like me who saw what the insurance industry did to psychiatry? I think after tonight I understand what it is like to figuratively be raped. Really! To have your personal being be violated"

I am willing to bet a few here do have an idea of what you feel, to be figuratively raped and have your personal being violated - these would be the people who have been involuntarily committed, searched, sometimes strip-searched, interrogated, and forced to voice their deepest, darkest secrets to a stranger as a condition of freedom - I suspect that they know exactly what you are talking about, and probably have an even deeper understanding of the feeling. This, then, is the psychiatry you propose is worth hundreds of thousands of dollars per year, the psychiatry that puts people through much worse than a few lines in an online blog that caused you so much personal anguish - perhaps you should seek a professional to help you deal with those feelings? I mean, it's expensive, and has no guarantees, but since you believe in it so much, I'm sure you'll be able to make the most out of it when dealing with your trauma. I wonder who specializes in cognative sexual assault, non-specific?

Nathan said...

I think Je Suis hits on on the mark in the difference between payment for psychiatric services vs. other medical services. Other medical fields work with actual pathology, and while the course of treatment is never exactly predictable, at least clearer diagnostics, mechanisms of pathology, and treatments available are seemingly more finite. The problems and goals addressed in psychiatric services are pretty nebulous, with no clear indicator of when "pathology" is addressed.

Psychiatrists don't quote estimates for treatment costs because they are not willing to make claims about the course of treatment. While there are unknowns and complications with other medical services, as a patient (or as an insurance company), I could reasonably price what an expected treatment for the assessing and possible removal of, for example, a precancerous growth on my skin.

Psychiatrists charge for outputs, not outcomes, and output/process does not seem to have much affect on outcome. For other medical services, outputs are more strongly related to outcome (diagnose ear infection and prescribe antibiotics [outputs] leads to no ear infection and no ear pain [outcome].)

R said...

As some others have mentioned, one of the differences between psychiatry and other medical fields is the frequency of appointments. If your poor but financially fairly financially stable (for example, like I was when I was a student or my first few years out of school), paying $150 once a year is doable, but paying $150 is not, and even paying $50 every month would be tricky. When I needed medical care that my insurance wouldn't cover that came out to about $180, my doctor let me may it off over the course of six months, paying $30/month. This doesn't work for psychiatry if your seeing someone monthly, or worse for therapy if your going weekly.

Dinah said...

80 hour work weeks? That's over 11 hours/day, 7 days a week with no rest. Je Suis, do you work that long? And I believe the national average for a shrink may be $180K.

Even though many psychiatrists are out of network, many health insurance policies still reimburse, the patient doesn't shoulder the full cost. But if the patient can't use their benefits, then as Lee said, the patient is the loser here (or can opt to see someone In network) and the insurance company gets off without paying a cent. Since patients are the customers the insurance company has to please, one thought would be that if patients complained about not being able to find in-network care, to the insurer and to the HR people where they worked, then the insurance companies would be pressured to offer doctors reasonable fees and easier paperwork.

Nathan: this one's for you:

Je Suis said...


You're right of course, I meant a 40 hour work week (I wrote that while under the influence of Lortab for a particularly painful abscess, and I see a few errors crept in).
I also see my math is off (if that's what one Lortab will do, why does anyone actually want these things?) - $150/hr at 40 hrs a week comes out to $312,000, not the $218,400 I originally posted. Even if that estimate is high (and it was based on Dr. Hassman's post) and the actual average is about $180,000 as you suggest, my point still stands. That's an enormous difference in a psychiatrist's income vs. the national average, and those that need psychiatric care the most are generally also those on the bottom of the socio-economic ladder, where they least can afford the 'care' they need. Yet psychiatry as a whole continues to force that care on these disadvantaged individuals, while attempting to defend the niche market pricing of their services - services that have no absolute outcome, but merely a vast array of probabilities as a result. Given this, I find it hard to swallow Dr. Hassman's assertion that these Physicians altruistically entered a field wherein the prevailing condition is one in which the majority of the people who need 'help' cannot afford that help, limiting their access to the well-off or wealthy, (a.k.a. the niche market I refer to). Due to this, I don't believe altruism was the primary motivator in their decision. No, I think money was talking a bit louder than good intentions at that point.

Anonymous said...


Thank to you posting the link to the NY Times article on specialists, I just realized that I needed to check to see what type of coverage I have for anesthesiology as I am planning on having out patient surgery. I have a bad feeling that it is going to be very hard to be able to access an in network provider but hopefully, I will be proven wrong.

And for Obama Care critics, this seems to be an issue with many insurance plans in the US. The "evil socialist" single payer plans don't have this problem.


Anonymous said...

I really think the leadership in psychiatry should have spent more of their focus on things like reimbursement (so psychiatrists might actually take insurance and medicare which would mean more patients getting care) rather than the DSM V - things that actually help patients. DSM V doesn't mean jack if the patient cannot get in to see the psychiatrist.


Nathan said...

I never said physician care is cheap or ethical, but more concretely priced with outputs more directly related to patient outcomes. It is no ok for physicians to proceed with non-emergency care without talking through the costs. I always here the "I have the patients best interest at heart when I make decisions without considering the finances" from doctors, but I find that outmoded. Quality care is efficient (most effective with fewest costs) and informed. Doctors should take time time to talk about the potential treatments that could be helpful, and their risks/costs, and work with the patient to decide what is best for them. If a procedure will cost $25,000 and is likely to have the same outcome as a procedure that that will cost $5,000, the doctor should ethically, in consultation with the patient, talk about the price of differences of choices.

Sunny CA said...

All of my doctors have fees that are higher than the insurance company reimburses, and the doctors bill me for the balance after the insurance company has decided how much they will pay. I paid my psychiatrist much more than the standard MD co-pay, because he told me that is what he charges in addition to insurance reimbursement.

You can charge you patients for the part of the fee that the insurance companies refuse to pay.

As far as the mound of paperwork, somebody needs to end the madness.

My one doctor who does not take insurance results in my paying 100% of his fee, since my insurance company paid nothing when I submitted the paperwork. Endocrinologist. $350 for 10 minutes. Makes psychiatrists seem a bargain, except I only see the endcrinologist twice a year.

As a patient I have a few gripes with insurance myself:
I paid roughly $1,500 a month for insurance last year, had more than $10,000 out of pocket medical expenses, but enough of my costs were disallowed by the insurance company so I never reached my deductible.

I switched to the Affordable Health Insurance, and my "affordable" payment is $1,148 a month, a cost that increased from the initially posted rate of about $960 a month when I consulted the rate charts October 1 to my December sign up. I have paid my January $1.148, but as of January 19th, I have no ID card, so still can't make a doctor's appointment. My payment is retroactive to January 1, but I effectively have not had insurance this month. They said I can pay full costs out of pocket and they will determine later if they are willing to pay.

As a patient who pays what I consider to be pretty hefty insurance payments, I find it annoying to pay full fee to a doctor who does not take insurance. If I could find an endcrinologist I like other than my royally expensive one, I would, but he is the best I have tried, and ultimately my health is worth it. To not take insurance, a doctor must be really good. Doctors who are not excellent will not retain private pay patients because patients can find mediocre doctors in network.

Anonymous said...

SunnyCA, I am perplexed as I saw a a doctor on 1/2 without an ID card under the ACA even though I had made my payment. Even though I had my ID number, I forgot to look up the group number. No problem as the doctor's staff person looked up everything and all I owed was the co-payment.

Sorry you have had so many difficulties. Can you get the card online?

My former psychiatrist only took one insurance plan which I didn't have but still charged one of the lowest rates in the area. He also was very accessible after regular hours. So I never felt his motivation was money in spite of complaints that my being on psych meds was useless treatment.

Steven Reidbord MD said...

Despite my avid interest in this topic, I've held back for a week to read others' comments. Dinah's post is a pretty level-headed account of why most psychiatrists, except those with high-volume, brief med-appointment practices, aren't on insurance panels.

In light of the comments here, I thought about my evening last night, when I decided to use public transit to go downtown. San Francisco's "Muni" is mediocre at best, and sure enough my trip was delayed and required an unexpected transfer. It was pretty irritating, but I got to my destination (just) in time anyway. By contrast, a taxi would have cost nearly 10x as much and they aren't always easy to catch. But once in a cab the trip is faster, more personalized, and less uncertain.

Not everyone can afford a cab, including some of the people most in need of one. Nonetheless, we don't assume taxi companies are out to gouge anyone, nor that they crassly "put money first" and "squeeze the poor". A cab ride costs more than a bus ride to get to the same place because it costs more to provide, and because the "creature comforts" are superior. Even someone like me who can afford cabs sometimes takes the bus; if they cost the same I never would.

The analogy to mental health care isn't perfect. I could have decided not to go downtown at all last night, whereas a patient in crisis may not consider a psychiatric visit optional. And cab rates are regulated and standardized within a city. But to me the comparison illustrates that there is nothing inherently suspect about providing a private service, even one lacking guaranteed outcomes or empirical superiority, as an alternative to more widely accessible and affordable options.

The comparison to health insurance is that coverage, public or private, will always be more like bus tokens than cab vouchers. Wealth helps one get downtown quickly, or see the "best doctor in town", even when public transit and health coverage are available — as they certainly should be.

Anonymous said...

I think the analogy is not a good one because mental health care simply is not available for the poor like public transit is. It's not a matter of wanting a better doctor or wanting better care, it's accessing care at all that's the problem.

When I was most ill, indigent, etc, I would have been looking at a long waiting list, it would have required going to a particular office to get a form to prove lack of income, etc. Is it common sense to think someone who is that ill is going to be able to handle all that is required to access those services? No. So, they don't go. Likewise, although I qualified, I didn't go sign up for food stamps, I simply didn't eat. Apparently I looked so skeletal at one point, a doctor actually handed me money for food. This is the reality of what happens when people are too disorganized and/or ill to go through all the hoops required to get community services.

Public transit requires a bus ticket. That's it. It's not hard to pull it together enough to come up with the means for public transit. It's a lot more reliable.

We have to do a much better job providing access to the poor.


Steven Reidbord MD said...

@P-K: I agree that mental health care is not available for the poor like public transit is. This is a political/public problem, with political solutions: hold rallies, sign petitions, vote the bums out, etc. My analogy, admittedly faulty in a number of ways, was about providing private services over and above what is available in the public sector, or even through commercial health plans. Yes, we have to do a much better job providing access to the poor. However, even in a best-case scenario, as long as there is poverty and wealth, the poor will never have the same services the wealthy have.

jesse said...

I too have held off responding. Dinah has written an excellent post and I agree with what she says. I would add, though, one point that has not yet been mentioned. In my experience psychiatrists care a great deal about their patients and feel a real commitment to helping them. Psychiatric intervention might be limited to a few sessions per year or sessions that are several times per week. There is great flexibility and this has to do with the goals of the treatment.

In my several decades of working with patients there has not been one time when zi stopped working with a patient who wanted to continue treatment because of finances. There was always a way to come to some agreement, whether it meant seeing that patient at vastly reduced rates or decreasing the frequency of the sessions, or both. And I know many psychiatrists who can say the same thing.

Psychiatrists who work in a system or for a group that sets policy might not have this flexibility. But i completely believe that no one goes into psychiatry as a profession unless he cares about people. Yes, I am fortunate in the way I practice and in the fact that I have that flexibility, but I know many psychiatrists who can say that their decisions of how to practice were made for reasons of what they thought best for their patients and not for what would reimburse them the most.

Dinah herself represents the best in psychiatry: a commitment to understanding and helping people.

Sunny CA said...

To anonymous:

I do not have an insurance ID number yet. I signed up through Covered California website, then was emailed instructions by Covered California to not contact the insurance company after signing up, but to wait for a letter of instruction on how to make payment which would be sent by the insurance company. When I had not gotten the letter of instruction by January 6th (the original last day to pay for January, before it was changed to January 15), I called Anthem Blue Cross, and they took my checking account information. I asked for an ID number and they told me I would have to wait for a packet with the ID card in it. Their estimate was 25 day wait. My internist, Dr. John Jones, Oakland, receptionist said that anyone with the Affordable Care Act coverage must go through their business office and have their policy approved before being allowed to make an appointment. I have not tried making other appointments, but assume I would be regarded as uninsured without proof of insurance. Meanwhile, Anthem Blue Cross has sent me a letter confirming that I cancelled my former Individual policy, then they sent a letter which is a certificate of former insurance for my former policy, but they have never sent the instructions on how to make payment on my ACA policy, nor has my packet arrived.

Je Suis said...

@Dr Reidbord

Your public transportation analogy regarding mental health care is indeed flawed, in a number of ways. off hand these spring to mind:

1)The transportation required to get you to your destination is limited in cost and duration, meaning that there is a fixed outcome with a set price - the bus fare or a regulated taxi fee, for a set distance. Not so with mental health care, which can run on indefinitely, with ever-escalating pricing.

2) As you stated, you could have chosen not to engage the services of public or private transportation at all. As far as I know, no bus or taxi driver holds the authority to force someone into their vehicle against their will, while mental health providers carry that constant threat with them at all times.

3) Once on the bus, or in a cab, you still have the option of leaving by getting off at the next stop - or the next corner - unlike the 'patient' who has been involuntarily committed. The driver is not the authority on when you are free to go; instead, you retain your autonomy.

4) An interaction with a bus or taxi driver does not have the potential to strip you of certain constitutionally guaranteed rights based solely on the driver's opinion of 'dangerousness'.

5) You are not permanently flagged as problematic in an electronic database, nor do you carry a history of habitual transportation use. You are not subject to the myriad ways in which someone with a mental health history is treated differently by health care and law enforcement personnel here - there is no stigma attached to public transportation use, unlike mental health care services usage. If you doubt this, just look at the mass shootings, or any recent major newsworthy event with a perpetrator; among the first things reported is whether the actor in the incident had a history of mental health issues. There doesn't seem to be much interest in how they arrived at the location of the incident, however.

So: force, stigma, loss of freedom, rights, dignity and autonomy, as well as economic hardships, are all absent in your encounters with public transportation (well, with the possible exception of dignity, of course - that is questionable), while remaining a valid concern in encounters with mental health care - really, the analogy is anything but. The parallels are shallow at best.

P.S. I found this interesting:
"I agree that mental health care is not available for the poor like public transit is" - "My analogy".. "was about providing private services over and above what is available in the public sector"

This simply states that the real 'care' is reserved for the wealthy, acknowledging the deplorable state of mental health care for the poor while distancing oneself from it. Simply put, it's a business. Fine, but then let's stop with the enforced business practices, such as involuntary commitments. As a business, it should be completely optional, and you are free to charge as you wish.

Dinah said...

I'm going to disagree here that the poorest and most vulnerable members of society have no access to care. I've worked in Community Mental Health Centers for 20 years. Yes, there is some waiting/paperwork to get in the door, but someone does it because many people are treated in these clinics. And the poorest and sickest of people have Medicaid and Medicare -- if they get sick enough, they get hospitalized and the hospital gets them enrolled (so they can get paid, granted, but it happens). It may not be perfect, there may be the P-K's out there who can't negotiate it and would starve before figuring out how to apply for food stamps, but it may be a long cry to a paper-work free America, and even to enroll your in child in free public schools, you have to get them vaccinated, produce paperwork, and register them. You have to get to Dr. Reidbord's bus stop, so to speak.

And out-of-network care is not un-reimbursed-- most people get a chunk back; some tell me they get full reimbursement for the sessions.

When it comes to medical care of all types, it's the working (or not working) poor who get screwed. They earn too much to qualify for Medicaid, but often have jobs that offer no health insurance. Or substandard insurance with no mental health benefits or no out-of-network benefits. They are the people with 2 weeks vacation, and no time for doctor's appointments, who reserve their resources for their children. No room on the bus and not a taxi in sight.

catlover said...

" They are the people with 2 weeks vacation, and no time for doctor's appointments, who reserve their resources for their children." I wonder if this a typo? A lot of working poor have zero vacation time and only get time off when they lose their jobs.

Steven Reidbord MD said...

@Je Suis: I'm glad we agree my analogy was flawed. Isn't it nice to chat with people of like mind?

You'll be happy to know that your incessant repetition about involuntary commitment and your right to commit suicide doesn't apply here. I can't recall the last time I committed anyone — it must have been 20 years ago. People are free to leave my taxicab anytime and for any reason, including if the meter reads higher than they are able or willing to pay. Moreover, many who come to see me do so to *avoid* electronic databases and recorded medical histories that are out of their control. Nothing leaves my office without my patient's permission. Those of us in private office practices, outside of insurance networks, are the *least* likely to offend you. Makes you feel good, yes?

Early in my career, I worked in a Community Mental Health Center for 3 years, not the 20 that Dinah can claim. Both the patients and the providers at CMHCs face limited resources and much added stress. Nonetheless, "real care" does happen there. I wouldn't call it deplorable, but it could certainly be improved if our society made it a higher priority. I have a great deal of respect for my colleagues who work in these challenging settings, and equally for the patients who do the best they can with limited resources. I feel, too, for the poor souls stuck waiting for the Muni bus on a cold foggy night, and I feel grateful I have other options.

Je Suis said...


No one said that the poorest and most vulnerable members of society have no access to care - I know I didn't at least - and I am not denigrating the work done in community mental health centers. Far from it. I am saying the same thing you posted, that it's the working (or not working) poor who get screwed. This includes the people on Medicare or Medicaid; you cannot really equate the care allowed under those plans to the resources available to the wealthy (or well-off even), now, can you? Someone able to finance their own care, free of insurance restrictions (or able to finance beyond those restrictions) or Governmental oversight (in the cases of Medicaid/Medicare) is going to receive a greater slice of that health care pie. It only stands to reason, greater resources equals greater opportunities, or better access if you will. There is no secret, no mystery, here - it's basically the same reasoning used to justify charging what seems to be exorbitant prices to many. Those that can afford it, will, and those that cannot, well, in the words of Dr. Reidbord " as long as there is poverty and wealth, the poor will never have the same services the wealthy have".

Anonymous said...

Dr. Reidbord, thanks for clarifying. I understand what you're saying and I agree, the services of the wealthy and the poor will never be equal. Maybe I'm just biased because services for the poor are particularly absent in my state, we rank near the bottom in spending on mental health, and I think it shows.

I suspect things in my state may look a little different than they look in Maryland, for example, I doubt there are as many services available for the poor here, because of our lack of spending on mental health.

There is a bright spot, though. I've seen some amazing things happen with services for the homeless in a large city in my state. They combine mental health care with primary care, assistance with food, etc. There's none of this - go to this office to get this form, or that form, etc, it's simply show up. That's more of the approach that's needed with treating the indigent with severe mental illness, at least in the beginning, it just doesn't make sense to require a buttload of obstacles to get people in the door, particularly when many people aren't too keen on seeing a psychiatrist to begin with.

Anyway, I think things could be better. But, we have a long way to go.


Je Suis said...

@Dr. Reidbord

I am sure it must be nice to chat with people of a like mind (or not, I can think of a few issues with that..), but I can't say for certain - if it ever happens, I'll let you know.

Btw, I was being generous in saying that your analysis was flawed, as a flaw is (per Merriam-Webster):

1) a defect in physical structure or form, or

2) an imperfection or weakness and especially one that detracts from the whole or hinders effectiveness.

As I tried to point out, there are such fundamental differences in the two objects of your analogy that to call it flawed is disingenuous at best. It's not a "flaw" if they share merely surface similarities (i.e. both are services) but otherwise are nothing alike, it's a failed analogy that falls apart in the face of the irreconcilable differences.

My "incessant repetition about involuntary commitment and your right to commit suicide" does indeed apply here, although I don't think you understand why that is. Let me try to explain.
Involuntary commitment is the elephant in the room here - basically, the gist is that psychiatry is a business, and can charge what the market will bear. However, that market is ofttimes forced to bear a cost that would otherwise be rejected via the machinations of involuntary commitment. It creates a captive audience, literally. It's like you're playing a game, but the hand you've (the mental health professional) been dealt has a joker in it that acts as a wild card; no matter what the other player (client or patient or whatever you like) holds, he or she cannot win, as your joker always trumps the hand. Always.
That joker is involuntary commitment. It creates a kind of fear, a fear that prevents some from even attempting to access mental health care, a fear that causes some to withhold information or downplay symptoms, a fear of the mental health professional themselves. A fear of loss. Unfortunately, especially with some of the new legislation being passed and/or considered, it's a very real and founded fear. This is why the "incessant repetition", to bring to light a very real, and very much flawed (see definition 2) aspect of psychiatry.

So, great, you've not committed anyone in a long time - have you ever? You seem to think that the immediacy of the event is what's important, while it's the ability to initiate an involuntary commitment - acted upon or not - that's the real issue. Power restrained is still power, and still a threat.

As for the "right" to commit suicide - there does not need to be a right, there simply needs to be the ability to say no. No to interference, should that be the decision you make. As I have mentioned, psychiatric outcomes are vague at best, and depending on ones economic abilities, care may be very much restricted, or else forced to the point of bankruptcy. The poor receive mainly medications, ones that have been getting a lot of attention lately as lacking efficacy, especially over the long haul. Therapy is mainly for the wealthy, what with the high rates psychiatrists charge and that many don't participate with insurance networks (see, well, this post). So, with outcomes in doubt, and access limited, sometimes severely, as well as the distinct losses associated with an involuntary commitment, what is the point in forcing this kind of care on someone who is unwilling?
Someone who is already suffering so much that their end is a relief? If you have nothing better to offer, then it is merely sadistic to force someone to endure these hardships on top on those that brought them to the brink in the first place.

Steven Reidbord MD said...

@P-K: Improving mental health services for the poor is an area of common concern for providers and patients/clients. I agree that "wraparound" services enhance access, and also supply basic necessities such as shelter and food, which can take priority over psychiatric care proper.

@je suis: If my potential to apply a 72-hour hold, not used in decades, is a fearsome threat, it must be as well for others who can apply one. Here in California these include all sworn peace officers (e.g., police), as well as individual mental health professionals authorized by each county. This pdf list for Santa Clara Co. shows the many nurses, clinical social workers, psychologists, and others who are authorized, generally because they work in public settings with severely disturbed clients, and they opted to receive extra training to get the authorization. A patient is far more likely to be involuntarily committed by one of these non-psychiatrists than by me in my office — because "holdable" patients don't generally come to see me, and when they do, I do my utmost to find alternatives to 5150'ing them. Using me to illustrate the fearsome threat of commitment is like using a peace activist to illustrate the inherent warlike nature of human beings. Yes, I could commit someone, but I'm a singularly bad example. That's why I said your concern about forced treatment doesn't apply in this discussion of out-of-network office-based psychiatrists. More precisely, it would apply as well, i.e., as little, to general discussions of psychiatric nursing, social work, clinical psychology, etc.

Since we're veering off topic, you can have the last word if you wish.

Borderline said...

I think it all probably depends on where you live, but I know for certain that there is no access to mental health care for medicaid patients in my town. The nearest place is a 45 minute drive away and can take several hours by bus. There are also no 24 hours buses, and they all shut down in the evening, so you might not get home. I'm not using Medicaid but I see a pdoc who works nights and I have to get a ride back if I want to see him cuz the buses stop running. In fact wealthier folk have actually complained about the fact that there is not mental health care available for the town's mentally ill homeless.

It's so interesting to hear Steve Reidbord write, because I have always dreamed of one day moving the San Francisco bay area because of their wonderful public transit. They have trolleys, buses that run all night, the BART (underground subway thingy)...I guess it all depends on how you look at things. I always think of San Francisco as public transportation heaven for California. I live closer to Los Angeles and I've met people who live in LA who didn't even know that LA has a subway. Now there's a major city with some public transportation issues. Still better than where I live, but remarkably worse than SF.

What's the saying? SF was built vertically. LA was built horizontally (to accommodate all the cars).

Je Suis said...

@Dr. Reidbord

You seem to think that the potential to commit an act - without consequences; i.e. sanctioned by law and thus inviolate for all intents and purposes - does not, by default, cause numerous problems. it does. I have mentioned a few, but most likely not all, and yet no mention is made of the difficulties caused to the victim (for want of a better word..) of such an action. Why is that?

I agree that the ability to detain someone against their will is a threat, no matter who holds that ability. Police, nurses, psychiatrists, whomever holds the capacity to initiate such a hold has the potential for harm. It is a situation that is too easily abused; and before you say nay, I have seen such abuses firsthand.
Make light of the "fearsome threat" all you want, but I have known individuals that truly needed psychiatric intervention - and this is me saying that, remember; it's not something I say lightly - and I have heard all about their fear of just such an occurrence. That fear kept them from even attempting to access "help"; essentially, a cornerstone of psychiatry is preventing the practice of psychiatry. Ironic, huh? And sad. So very, very sad; and many times, so very, very unnecessary.

So "holdable" patients don't generally come to you? Perhaps that's because you are in a private practice, and do not accept insurance? The worst cases are also the ones who cannot afford your fees - there, we're back on track with psychiatric reimbursements, making this post relevant to the discussion - so I would venture that you are treating mostly the 'neurotic wealthy'. That would make it a bit easier to not initiate a hold, I suppose. A win-win situation, seemingly.

A peace activist? Really? So, in light of that comparison, do you actively demonstrate against involuntary commitment? Do you speak out against it? If not, then the correlation lacks a certain something. There is also a certain conflict of interest involved - an involuntary commitment, however initiated, inevitably leads to an encounter with psychiatry. It has the potential to be a self-sustaining system; those who benefit are also those who can initiate. Sounds more like a drug pusher, get em in and hooked on your product, then sit back and reap the benefits. I think I like that juxtaposition a little better.
It has a certain je ne sais quois, nest-ce pas?

Thanks for the last word, by the way - I always wondered who held dominion over that. Now I know.

Anonymous said...

Je Suis,

You and everyone else might be interested in this horrific article about a woman held against her will right after her husband murdered her teenage son and then committed suicide. And her insurance company is being billed for charges that she is fighting.

Nathan said...

How's this for analogy:

The US military hasn't activated its selective service list in over 40 years (psychiatrists not involuntarily committing for a long time), but it doesn't mean that it can't or won't (pervasive power dynamic of psychiatrists/others). But if a volunteer armed forced wasn't cutting it (self-pay clients) and the Pentagon and all of their contractors still wanted government contracts (hospitals and drug companies), I would not be surprised if the Draft returned (increases in involuntary commitment).

The US government also creates a disincentive of possible jail time and fines for people who don't register (threats of harsher treatment/diagnoses/longer stays if not compliant to treatment plan whether agreed to or not). This is to keep folks from actively protesting for fear or worse things than possible deployment (structural factors that keeps people from questioning or seeking alternative treatment).

I'm not a big fan analogies, but thought I'd throw one out as some here like engaging with them.

Dinah said...

This is post about why psychiatrists don't take insurance, not about involuntary commitment. Shrink Rap has many posts up on involuntary commitment, please feel free to comment on those if you're interested in that subject line.

Anonymous said...

@Nathan - your comment is brilliant. As we French say, Touché.

Steven Reidbord MD said...

@Dinah, congrats on reposting this article to KevinMD.

Dinah said...

This post is up on Kevin MD at

You all might like reading the comments there (the post is verbatim, so if you do surf over, go straight to the comments)

Tracey said...

I think someone needs a script for an antianxiety medication sprinkled with empathy and the ability to tolerate another point of view from people in a weaker position.